Establishing Long-Term Efficacy in Chronic Disease: Use of Recursive Partitioning and Propensity Score Adjustment to Estimate Outcome in MS

Context Establishing the long-term benefit of therapy in chronic diseases has been challenging. Long-term studies require non-randomized designs and, thus, are often confounded by biases. For example, although disease-modifying therapy in MS has a convincing benefit on several short-term outcome-measures in randomized trials, its impact on long-term function remains uncertain. Objective Data from the 16-year Long-Term Follow-up study of interferon-beta-1b is used to assess the relationship between drug-exposure and long-term disability in MS patients. Design/Setting To mitigate the bias of outcome-dependent exposure variation in non-randomized long-term studies, drug-exposure was measured as the medication-possession-ratio, adjusted up or down according to multiple different weighting-schemes based on MS severity and MS duration at treatment initiation. A recursive-partitioning algorithm assessed whether exposure (using any weighing scheme) affected long-term outcome. The optimal cut-point that was used to define “high” or “low” exposure-groups was chosen by the algorithm. Subsequent to verification of an exposure-impact that included all predictor variables, the two groups were compared using a weighted propensity-stratified analysis in order to mitigate any treatment-selection bias that may have been present. Finally, multiple sensitivity-analyses were undertaken using different definitions of long-term outcome and different assumptions about the data. Main Outcome Measure Long-Term Disability. Results In these analyses, the same weighting-scheme was consistently selected by the recursive-partitioning algorithm. This scheme reduced (down-weighted) the effectiveness of drug exposure as either disease duration or disability at treatment-onset increased. Applying this scheme and using propensity-stratification to further mitigate bias, high-exposure had a consistently better clinical outcome compared to low-exposure (Cox proportional hazard ratio = 0.30–0.42; p<0.0001). Conclusions Early initiation and sustained use of interferon-beta-1b has a beneficial impact on long-term outcome in MS. Our analysis strategy provides a methodological framework for bias-mitigation in the analysis of non-randomized clinical data. Trial Registration Clinicaltrials.gov NCT00206635


1.
Title page A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis:

The cohort of untreated patients in Britain
It is acknowledged that more than 15 years have passed since the original recruitment period (1988/1989). The extent, quality, and availability of the patients' documentation may hamper the recruitment of the targeted 60 untreated patients of the UK cohort. Therefore, it is also an aim of this study to explore the feasibility of recruiting a cohort of untreated patients with a longstanding diagnosis of MS and to explore the suitability of such a cohort to serve as a control group for open long-term follow-up studies.
Feasibility will be checked frequently between the Sponsor and the investigators.
Furthermore, it is acknowledged that the recruitment of the UK cohort could be affected by bias when compared to the selection of the patients of the original pivotal study due to but not limited to the following facts: • different medico-social circumstances in North America and Britain, e.g. access to a neurologist, with impact on the following variables: -diagnosis of MS / perceived duration of disease -diagnosis of relapses (perception of symptomatology by patient and/or medical professional) -completeness of documentation of relapses and other disease characteristics • impact of potential treatment 'triage' in favor of patients with a very aggressive course of disease (e.g., treatment with azathioprine, mitoxantrone, or other 'more accessible' agents may lead to exclusion of the patients with a more severe course of the disease) • matching of patients with conversion to secondary progressive multiple sclerosis (SPMS) • matching of patients with a fatal outcome It should be noted that the bias discussed here may result in recruitment of a cohort with a more benign course of the disease. Furthermore, a suspected lower rate of documented relapses and other disease characteristics may favor the perception of the course of disease in the UK cohort. 7. Need for concomitant therapy with corticosteroids or ACTH or therapy with these agents within 30 days prior to entry into the study. 8. Previous immunosuppressive therapy with cytotoxic chemotherapy. 9. Observation by the principal investigators or their staff at participating institutions cannot be assured for the duration of the study. 10. Upper extremity disability that prevents self-administration of subcutaneous medication, and the absence of a friend or family member who can reliably administer the subcutaneous injections. 11. Patients who are in relapse or who have entered a progressive phase of their illness at time of entry into the study.
12. Allergy to acetaminophen. 13. Need for chronic concurrent therapy with aspirin or non-steroidal anti-inflamatory drugs.
14. Use of other investigational drugs in the 30 days preceding study entry.
For feasibility reasons, the following selection criteria were chosen for enrollment of the untreated patients of the UK Inclusion criteria: • In the calendar years 1988-1989: -clinically definite MS or laboratory-supported definite MS (Poser criteria) for not less than one year at date of qualification in 1988/89 -a history of clearly defined relapses and remissions, with at least two relapses in the 2 years preceding the date of qualification in 1988/89 -18 to 50 years of age at the date of qualification in 1988/89 -EDSS score below 6.0 / ambulatory at the date of qualification in 1988/89 Please, note: if an EDSS score below 6 -MS that has been stable for at least 30 days -Signed and dated informed consent Exclusion criteria: • Primary progressive multiple sclerosis (PPMS) at any time • Any previous treatment with immunomodulatory agents including any interferon or glatiramer acetate, bone marrow transplantation, or immunosuppressive agents (corticosteroids are not concerned) • Any previous treatment with putative experimental MS treatments -only in case of a plausible mechanism of action for the putative intervention (questionable prior interventions should be discussed with the Sponsor's Core Clinician) • known hypersensitivity to gadolinium-DTPA • The symptoms / signs indicative for MS may be better explained or confounded by another disease process (e.g., neoplastic processes) More detailed guidance for the selection of the UK cohort may be provided in a separate Working Procedure.

Removal of patients from treatment or assessment
Removal of patients from treatment is not applicable as no study-induced treatment will be administered (cf. Section 7.4, page 16).
The following medical conditions will lead to a removal from assessments for patients of the UK cohort: • acute severe hypersensitivity reaction against gadolinium-DTPA • patient in need for acute treatment with glucocorticoids • conditions violating the selection criteria (cf. Section 7.3.2, page 13) In such cases, the patient has to be withdrawn from assessment and should be replaced. The withdrawal of such patients will be documented and reasons for the withdrawal of the patient will be provided.
Patients in the NA cohort will not be removed from assessment. Should acute medical conditions prevent an immediate assessment of the NA patients, the assessment should be postponed until the protocol-stipulated investigations can be performed.

MRI X X
Retrospective data review X X a If not neurologically stable, postpone visit for minimum of 30 days. b Visit activities may be completed on separate days within a suggested 21-day period after signing of the informed consent. c Informed consent must be signed before any study procedures are performed. d EDSS score determined prior to evaluator's knowledge of previous EDSS score and history. e Neuropsychological testing should take approximately 55 min. f Self-assessment scale; will be included in the patients' booklet of the CRF. g Subject to a separate informed consent and not mandatory for participation in the study.

Patient-reported measures: Mood, quality of life, utilities, and resource use
All patient-reported measures -mood, quality of life, resource use -will be self-administered using validated questionnaires. The questionnaires should be the first examination of the day. There should be a 30 minute break for rest after completion and before other examinations. The following questionnaires will be administered in the order listed below: • the EuroQuol 5-dimensional questionnaire (EQ-5D; EuroQol Group 1990), and • the Functional Assessment of Multiple Sclerosis (FAMS; ,

Study Protocol
No. 308272 Trained study professionals should ensure that patients have sufficient time and privacy to complete the questionnaire. After questionnaires are explained to the patient, he/she will be asked to fill out the questionnaires as completely and accurately as possible. Assistance will be provided to patients who have difficulty with reading. Study professionals should check immediately afterwards that only one box has been ticked for each question and that every question has been answered.

Neuropsychological evaluations
It is suggested to perform the neuropsychological evaluations on all patients within 21 days after signing the informed consent.
If all study investigations will be performed during one day, the neuropsychological assessment should be done after a 30 minute break for rest after completion of patients' questionnaires and before all other examinations. Should the study investigations be performed during more than one day, the neuropsychological assessment should be performed during the second day as the first examination of the day.
The battery of tests to be used in this study is based on the "Minimal Assessment of Cognitive Function in MS (MACFIMS)" proposed by a panel of neuropsychologists and psychologists (Benedict et al 2002). The battery has been modified for the purpose of this study with regard to the following: • The NART will be replaced by the WTAR. The WTAR provides the same stimuli for US and UK populations and has a set of norm data for each of theses countries. • The PASAT (3-second version; PASAT-3'') will be performed as a part of the MSFC (cf. Section 7.5.2.4, page 21).
The assessments of this modified battery will evaluate the cognitive domains "processing speed/working memory", "learning and memory", "executive function", "sustained attention", and "language" in the context of potential confounds to test interpretation (premorbid cognitive ability, mood, and visual acuity).
The neuropsychological tests include the following scales and tasks (all referenced in Benedict et al. 2002):

Total 55
A proportion of patients may not have English as a first language, among them patients in Canada with French as a first language. A comparable neuropsychological test battery for patients with French as a first language will be provided in a separate document. Patients with neither English or French as a first language will be invited to take the tests in the provided English versions. Participation will be strictly voluntary. The patient information will point out the voluntary participation. The test results of patients with a first language other than English will be evaluated separately.
Patients with severe cognitive impairment provide special problems. Although there would be reason to exclude them since they may not be able to carry out some tests requiring a higher degree of cognitive function, they represent an extreme of outcome that would contribute to the validation of efficacy. It is obvious that tests can not be scored which the patients are not able to do and it is recognized that the cognitive impairment shown by a few patients will nevertheless be counted in the Kurtzke functional scale and in the Expanded Disability Status Scale (EDSS). However there may still be useful data obtained from the subtests which can be scored. Inability to carry out tests would be thought by some to constitute a zero score, therefore, it is planned to analyze the data in a number of ways to encompass the breadth of opinion as this is an exploratory study. This flexibility may aid in the generation of hypotheses.
Investigators should clearly indicate in the CRF such patients that • in the judgement of the examiner have severe cognitive impairment that makes neuropsychological assessment inappropriate, and/or • have a visual impairment that makes tests with visual stimuli inappropriate. The criterion will be the Rosenbaum visual screener, 20/50-70 threshold at 14'' from corrected eye.
Administration time will vary depending upon the ability of the patient. Total administration time for all three measures should be approximately 20-30 minutes. The MSFC measures are administered in person by a trained examiner. The examiner need not be a physician or nurse.
The MSFC can produce scores for each of the three individual measures as well as a composite score. In addition, there are a variety of ways to calculate scores depending on the nature of the study and sample. All three measures have been shown to have good inter-rater and test-retest reliability. In addition, there is considerable evidence for their validity and sensitivity to clinically relevant change in MS patients.

Functional Systems Scores and Expanded Disability Status Scale
The Functional Systems Scores (FSS) and Expanded Disability Status Scale (EDSS) are probably the most widely utilized assessment instruments in MS (Kurtzke 1983). Based on a standard neurological examination, optic, brain stem/cranial nerves, pyramidal, cerebellar, sensory, vegetative, and cerebral functions (the seven "functional systems") are rated. These ratings are then used in conjunction with observations and information concerning gait and use of assistive devices to rate the EDSS. Each of the FSS is an ordinal clinical rating scale ranging from 0 to 5 or 6. The EDSS is an ordinal clinical rating scale ranging from 0 (normal neurologic examination) to 10 (death due to MS) in half-point increments.
Administration time will vary depending upon the condition of the patient and the skill of the examiner. Although the FSS and EDSS themselves can be rated in a few minutes, the neurological examination that is needed to make the ratings can take 15-30 minutes.
The FSS and EDSS will be administered in person by a trained examiner, preferably a neurologist. However, nurse practitioners with the proper training can also complete the neurological examination and rate the FSS and EDSS.
The FSS and EDSS were developed in the 1950's and refined in the 1980's to provide a standardized measure of global neurological impairment in MS. Both test-retest reliability and inter-rater agreement have varied considerably from study to study with some studies finding high values and other studies rather low figures. Therefore, the EDSS represents a widely used albeit imperfect standard. The EDSS was also used during the Betaseron ® pivotal study. It should be noted that an earlier predecessor version of the EDSS, the so-called DSS was used in the NH cohort.
EDSS scores 1.0 to 4.5 describe people with MS who are fully ambulatory; EDSS scores 5.0 to 9.5 are defined by the extent of impairment of ambulation. Times to reach certain EDSS scores are considered endpoints in this trial. Investigators must use their discretion to determine whether the following conditions apply: EDSS Score of 3.0 An EDSS score of 3.0 describes patients who are ambulatory without the aid of a device, but their disability interferes with their daily lives. If an EDSS score of 3.0 is not documented in the patient chart, investigators must make a determination using the following guidelines: • When did patients notice that a full day did not pass without experiencing difficulty?
• When did patients have to decrease their hours at work to less than full-time?
• When did others notice a decrease in the patient's function?
The final determination will be made at the discretion of the investigators.
EDSS Score of 6.0 An EDSS score of 6.0 describes patients who require some assistance with ambulation. If an EDSS score of 6.0 is not documented in the patient chart, investigators must make a determination using the following guidelines: • When did patients begin using an assistance device (e.g., cane or walker)? (Note: The investigator should attempt to distinguish between the use of an assistance device for comfort and the use of an assistance device out of necessity.) • When did patients first fall secondary to MS?
• When did patients first require an assistance device in order to leave their house?
The final determination will be made at the discretion of the investigators.
Conventions for consistency of EDSS scoring: Since comparisons of outcomes in this study will be made to natural-history data it is important that EDSS, scored at long-term evaluations, be made to conform with a few of the conventions which were used in the natural history data. The first of these is that EDSS scores were felt to be confirmed if the patient had the same EDSS or worse one year later. If this confirmation was found, the first appearance of the EDSS score was backdated to the original observation the previous year. Accordingly, this will mean that the collection of EDSS scores in the protocol will be made more reliable if it is possible to get scores from the previous two years. It is recognized that this will not be possible in all cases although a combination of historical record from the patient themselves, confirmed by their spouse or caretaker, may be necessary in some circumstances to add support to the neurologist's best opinion of where the patient was a year previously. To illustrate this, a patient seen at EDSS 3 who is 4 a year later but two years later had reverted to 3 would not be considered to have reached a confirmed 4. This convention proved to be operationally quite reliable since EDSS scores confirmed at a year virtually never reverted (<2% of cases).

7.5.2.6
Medical history The treating physician will ask about relevant diseases of the following organ systems: skin, eyes, ears, nose, and throat, head and neck (including the thyroid), lungs, heart, breasts, abdomen, lymph nodes, musculoskeletal system (including extremities and spine), genito-urinary system, gynecological organs, and rectum. History of allergies, in particular with respect to proteins, interferon, or gadolinium-DTPA will be queried, as well as other abnormalities (if indicated). Furthermore, patients will also be asked if they have a history of alcohol or drug abuse, or a history of psychiatric disorder, with particular regard to known depression or suicidal tendencies, head injuries, or epilepsy. Any previous disease or surgeries will also be documented. The oral history obtained from the patient or a caretaker should be supplemented by a thorough chart review and/or by an interview of the medical doctor currently attending the patient for his MS. The source of information will be recorded in the CRF.

MS history
Patients will be asked to provide the date of diagnosis of MS and their history of relapses (i.e., total number of relapses and number of relapses requiring treatment). The oral MS history obtained from the patient or a caretaker will be supplemented by a thorough chart review and/or by an interview of the medical doctor currently attending the patient for his MS. The source of information will be recorded in the CRF.
In general, investigators must use their discretion to determine whether the following conditions apply: Relapse (retrospective definition) A relapse is the appearance of new neurological abnormality or the reappearance of a neurological abnormality, separated by at least 30 days from onset of a preceding clinical demyelinating event. The abnormality must be present for at least 24 hours and occur in the absence of fever or known infection (fever is defined as axillary temperature >37.5°C).
If a relapse is not documented in the patient chart, investigators must make a determination using the following questions as guidelines: • Was the event described typical of a relapse? • Was the duration of the event typical of a relapse?
• Did other family members substantiate the occurrence of the event?
• Was the patient hospitalized?
• Was the relapse treated? If yes, were corticosteroids used for treatment?
The final determination will be made at the discretion of the investigators. Relapses confirmed by an objective neurological examination performed by a qualified health professional and relapses reported subjectively by the patient should be reported separately.
Secondary progressive multiple sclerosis (SPMS) If a diagnosis of SPMS is not documented in the patient chart, investigators must make a determination using the following guideline: SPMS is defined as a progressive deterioration of disability for at least 12 months with an increase of at least one point between EDSS scores over the last 2 years (or a 0.5increase between EDSS score of 6.0 and 6.5) with or without superimposed exacerbations following a relapsing-remitting course. The date of conversion to secondary progressive disease will be backdated to the onset of the deterioration in disability. In the opinion of the investigator, the deterioration of disability was not caused by relapses.
The final determination will be made at the discretion of the investigators.
There has been no formal definition of SPMS in the original protocol, patients were -howeverwithdrawn from the study in case of "a phase of increasing disability that progresses unremittingly for six consecutive months" without specification of a EDSS quantification. Therefore, attempts should be made to reassess which of the patients of the NA cohort were true RRMS or rather SPMS patients at the date of study entry in 1988/89 applying the RRMS definition provided by Lublin and Reingold 1996 and the SPMS definition provided above: Clearly defined disease relapses with full recovery or with sequelae and residual deficit upon recovery; periods between disease relapses characterized by a lack of disease progression.

Medication history
Patients in the NA cohort will be questioned about their use of established or putative MS medications since they left the Betaseron ® pivotal study. These medications might include Copaxone ® , Avonex ® , Rebif ® , azathioprine, cyclophosphamide, methotrexate, mitoxanthrone, or any other medications used as an immunosuppressive or MS-disease-modifying agent. Also, medication to treat MS-related symptoms should be recorded (this also applies for the patients of the UK cohort).
Furthermore, patients should be explicitly queried for medication potentially interfering with cognitive functions, e.g., antiepileptic drugs, hyponotics, sedatives, or antipsychotic medication. Patients will be asked to provide information on the length of time they took Betaseron ® and reason(s) for discontinuation. The oral medication history obtained from the patient or a caretaker will be supplemented by a thorough chart review and/or by an interview of the medical doctor currently attending the patient for his MS. The source of information will be recorded in the CRF.

Magnetic resonance imaging (MRI)
All patients (i.e., the NA and the UK cohort) will undergo a single MRI scan according to a predetermined protocol. All MRI scans will be evaluated at a central analysis center (MRI-AC).
Note: MRIs should not be performed within 30 days of the last administration of corticosteroids.
Scans will be performed with 0.1 mmol/kg gadolinium-DTPA given intravenously. This is a standard diagnostic procedure in MS. The contrast medium may occasionally cause nausea and vomiting. It may cause warmth and pain at the injection site. Allergic reactions occur very rarely (anaphylactic shock in 13 of 5 million applications, based on post-marketing surveillance) and can be potentially serious in extremely rare instances.
MRI investigators and technicians from each center will be informed about technical implementation and image quality assurance prior to the start of the study. Thereafter, each center will perform a test run to assess image quality, repositioning and shipment procedures (for hardcopy and electronic image shipment to MRI-AC), and to evaluate the compatibility of archive media and format. Once the dry run is accepted, the parameter settings should remain unchanged for all scans obtained from study patients. A site can only start enrollment after acceptance of the MRI test run by the MRI-AC.
Quality of all scans will be assessed by the MRI-AC. The scans should be sent as hard copy to the MRI-AC within two working days, preferably along with a copy of the electronic image data, unless alternative routes have been established. After check of scan parameters, image quality and repositioning a fax will be sent to the contributing site within two working days of receipt of the scan confirming acceptance or rejection of the scan. Rejected scans should be repeated without delay and within the suggested 21-day study period.
A separate manual will describe the technical and logistical aspects of the MRI procedures in detail.

Laboratory Tests
The laboratory studies should be performed within 21 days after signing the informed consent. They will be performed in the patients of the NA cohort only. All laboratory tests will be performed in the central laboratory ACM. One copy of the results will be sent to the respective site and another one to the CRO for recording into the database. Original laboratory reports will be maintained at the respective study centers, where investigators will confirm receipt and review of data by signing the laboratory form. Serum samples for neutralizing antibodies to IFNβ will be analyzed in a different central laboratory, i.e. at MediTest (Laupheim, Germany) but handled through the central clinical laboratory ACM.

TT 3 Laboratory Parameters
Blood chemistry creatinine, aspartate transaminase (AST/SGOT), alanine transaminase (ALT/SGPT), gamma glutamate transferase (γ-GT), alkaline phosphatase bilirubin, albumin Hematology erythrocytes, leukocytes, differential count, thrombocytes, hemoglobin, hematocrit Thyroid parameters thyroid-stimulating hormone (TSH) TPO-Thyroid microsomal Abs Neutralizing antibodies antibodies found to bind to interferon β will be evaluated for the neutralization of activity as measured in the MxA protein assay Other antibodies Rheumatoid arthritis, Lupus erythematodes In addition to the blood sampling for the above described laboratory investigations, one serum sample will be obtained and stored. It may be used for analyses of immunological parameters. Results may be compared with results generated in samples obtained during the pivotal study, where appropriate. The analyses may use proteonomic and metabolomic techniques.
Furthermore, it is intended to perform pharmacogenetic evaluations. The patient's participation in these pharmacogenetic evaluations will be subject to a separate informed consent and, therefore, will be optional and independent of the participation in the study. A patient's agreement to or refusal of consent for this sampling will have no effect on the remainder of the study procedures. The scientific, ethical, and procedural details of these evaluations are summarized in Appendix 12. Appendix 2 contains the separate patient information and informed consent form.
A separate manual will describe the technical and logistical aspects of the laboratory procedures in detail.

Adverse reactions
Patients on the NA cohort will be questioned about specific adverse reactions of Betaseron ® that they might have experienced since leaving the Betaseron ® pivotal study. These include flu-like symptoms, injection site reactions, fever, headache, malaise, myalgia, and increased liver transaminases. Those pre-specified adverse reactions will be only recorded for the duration of actual treatment with Betaseron ® . They will not be recorded for such times when patients did not receive Betaseron ® . In addition, discontinuation of Betaseron ® due to any adverse reactions, including the timing of that discontinuation, should also be documented.
Adverse events and serious adverse events will not be collected and followed other than described above. All adverse events that occurred since the clinical trial ended or that will occur in the future after the study visit (serious or non-serious) are assumed to have been, or will be, reported through the usual channels by the physician providing care to that patient. The only exemption is the investigational period. During that period, the usual AE reporting and followup as described in Section 7.5.5.1 (page 28 ff.) will be applied.

Study Protocol
No. 308272 Page: 27 of 43 Final Proposed Protocol / Version 3.0 for North America -20AUG2004

Appropriateness of measurements
The assessments proposed in this study protocol are considered to be "standard assessments", i.e., widely used and generally recognized as reliable, accurate, and relevant.

Primary efficacy variable(s)
This is primarily an observational and descriptive study. It is not possible to define a primary efficacy variable a priori. The study may generate hypotheses about potential efficacy-or effectiveness-related endpoints. Hypotheses may be tested in later follow-up studies based on endpoints identified and effect sizes observed in this study.

Efficacy and/or effectiveness related variable(s)
The following variables related to MS status and clinical symptomatology will be targeted: • Survival • Level of disability/function as measured by EDSS * • Level of disability/function as measured by MSFC • Time to EDSS level of 3.0 from retrospective data review* (in the subset of patients with an EDSS score < 3.0 before start of pivotal study) • Time to EDSS level of 6.0 from retrospective data review* • Ambulatory status (time to first use of an ambulatory device, time to dependence on an ambulatory device, time to first use of a wheelchair) • Conversion to secondary progressive multiple sclerosis (SPMS) The following MRI-derived variables will be targeted: • volume of hyperintense lesions on T2-weighted images ("T2 burden of disease"; T2-BOD) • normalized brain volume • number of gadolinium-enhancing lesions on T1-weighted images • number and volume of hypointense lesions on non-enhanced T1-weighted images ("black holes") • cervical cord imaging The MR spectroscopy as a method with putative information on demyelination and axonal loss may be applied as well in a subset of patients. Details on MR spectroscopy will be provided in a sub-study protocol for the study centers participating in that additional investigation.
In addition, scores from individual assessments of the neuropsychological and HRQoL scales and tests will be evaluated as variables with potential information about efficacy or effectiveness.

Adverse events
An adverse event (AE) is normally defined as any untoward medical occurrence in a patient administered a pharmaceutical product and which does not necessarily have to have a causal relationship with this treatment. As patients in this study will not receive any protocol-stipulated pharmaceutical product -with the exemption of gadolinium-DTPA -AEs in this study will be defined as any untoward medical occurrence in a patient administered any pharmaceutical product and which does not necessarily have to have a causal relationship with this pharmaceutical product.
An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not the AE is considered related to the medicinal product. AEs are to be coded using an internationally recognized dictionary.
It should be noted that only AEs occurring during the investigational period will be reported and followed as described in this Section.

Documentation
Attention is to be paid to the occurrence of AEs at all stages of the examination. Thus, the patient should be closely observed by the investigator both during and after the examination.
Any AEs (observed, volunteered, or elicited) are to be documented in detail indicated on the case report form (CRF). The following information is required. • The relationship of the AE a pharmaceutical product used by the patient • Any action taken by the investigator to resolve the AEs • The outcome of the AE (recovered/resolved, recovering/resolving, not recovered/not resolved, recovered/resolved with residual effects, fatal).
• The main pattern of the AE (every drug administration, intermittent, continuous, other).
• An assessment of the seriousness of the AE will be made by the investigator, who is to complete a special form provided by the Sponsor in the case of a serious adverse event (SAE). However, SAEs will also be recorded briefly on the "Adverse Event Form" of the CRF. A definition of SAEs is provided below.

Intensity
The investigator is to classify the intensity of an adverse event according to the following definitions:

Mild
The intensity of the AE is assessed as mild, taking into account the possible range of the intensity of the AE. An indicator could be the preservation of function in the concerned organ system despite the occurrence of the AE.

Moderate
The intensity of the AE is assessed as moderate, taking into account the possible range of the intensity of the AE. An indicator could be any of function in the concerned organ system.

Severe
The intensity of the AE is assessed as severe, taking into account the possible range of the intensity of the AE. An indicator could be the loss of function in the concerned organ system.

Relationship with a pharmaceutical product
The investigator is to classify the drug relationship of an AE according to the following definitions:

None
The time course between administration of the pharmaceutical product and occurrence or worsening of the AE rules out a causal relationship and/or another cause is confirmed and no indication of involvement of the pharmaceutical product in the occurrence/worsening of the AE exists.

Unlikely
The time course between administration of the pharmaceutical product and occurrence or worsening of the AE makes a causal relationship unlikely and/or the known effects of the pharmaceutical product or of the substance class provide no indication of involvement in occurrence/worsening of the AE and another cause adequately explaining the AE is known and/or regarding the occurrence/worsening of the AE a plausible causal chain may be deduced from the known effects of the pharmaceutical product or the substance class, but another cause is much more probable and/or another cause is confirmed and involvement of the pharmaceutical product in the occurrence/worsening of the AE is unlikely.

Possible
Regarding the occurrence/worsening of the AE, a plausible causal chain may be deduced from the pharmacological properties of the pharmaceutical product or the substance class, but another cause just as likely to be involved is also known or although the pharmacological properties of the pharmaceutical product or the substance class provide no indication of involvement in the occurrence/worsening of the AE, no other cause gives adequate explanation

Probable
The pharmacological properties of the pharmaceutical product or of the substance class and/or the course of the AE after dechallenge and, if applicable, after rechallenge and/or specific tests (e.g. positive allergy test, antibodies against pharmaceutical product/metabolites) suggest involvement of the pharmaceutical product in the occurrence/worsening of the AE, although another cause cannot be ruled out.

Definite
The pharmacological properties of the pharmaceutical product or of the substance class and the course of the AE after dechallenge and, if applicable, after rechallenge and specific tests (e.g. positive allergy test, antibodies against pharmaceutical product/metabolites) indicate involvement of the pharmaceutical product in the occurrence/worsening of the AE and no indication of other causes exists.

Unclassifiable
The available information is not sufficient for causality assessment. (The option "unclassifiable" is not available on the AE form.)

Serious adverse events
A serious adverse event (SAE) is classified as any untoward medical occurrence that at any dose • results in death, or • is life-threatening, or • requires inpatient hospitalization or prolongation of existing hospitalization, or • results in persistent or significant disability/ incapacity, or • is a congenital anomaly/ birth defect Medical and scientific judgment should be exercised in deciding whether expedited reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the patient or may require intervention to prevent one of the other outcomes listed in the definition above. These should also usually be considered serious. Examples of such events are intensive treatment in an emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization; or development of drug dependency or drug abuse.
The investigator should take appropriate diagnostic and therapeutic measures to minimize the risk to the patient. Where appropriate he/she should take diagnostic measures to collect evidence for clarification of the relationship between the SAE and the pharmaceutical product.
The investigator must submit a complete SAE Report for all SAEs, regardless of a possible causal relationship, to Berlex's Global Medical Safety Surveillance function immediately (at the latest within 48 hours of having gained knowledge of the event). This report is to be sent on the SAE Report Form provided by the Sponsor. The investigator is required to document in full the course of the SAE and any therapy given, including any relevant findings / records in the report. The investigator will also inform the Sponsor of the relevant follow up information and the outcome of the SAE as soon as possible using the Sponsor's standard form.
The primary contacts will be: All SAEs after signature of the informed consent must be documented.
In addition, SAEs will also briefly be recorded on the "Adverse Event Form" of the CRF if they occur after administration of treatment.
The injection itself may be accompanied by mild bruising and also, in rare cases, by a transient inflammation of the vessel wall. After initial irritation, the site of venipuncture is usually painless and hardly noticeable.
Risks related to blood sampling: On all visits including blood sampling, venipuncture with disposable needles will be performed, usually into cubital veins. Blood sampling may be accompanied by mild bruising and also, in rare cases, by a transient inflammation of the vessel wall. After initial irritation, the site of venipuncture is usually painless and hardly noticeable.
Blood loss: The total amount of blood withdrawn during the study will be approx. 40 mL at maximum* (i.e., approx. slightly less than three tablespoons or a tenth of a normal blood donation: 450 or 500 mL). For details, cf. TT 4 below: Examples would be (a) acute renal failure listed in the Investigator's Brochure with a subsequent new report of interstitial nephritis and (b) hepatitis with a first report of fulminant hepatitis. "Unexpected" as used in this definition, refers to an adverse drug experience that has not been previously observed and included in the product information rather than from the perspective of such experience not being anticipated from the pharmacological properties of the investigational product.

Pharmacokinetic and bioanalytical methods
There will be no pharmacokinetic investigations in the study. Certain proteins -as described below -may be used to get an estimate of bioavailability for patients with an ongoing treatment of Betaseron ® .
It is intended to compare samples preserved from the time of conduct of the pivotal study with a sample to be obtained in this study. Comparisons may include mass spectrometry-based analysis and broad profiling of proteins and low-molecular-weight organic molecules, cytometric analysis and profiling of different cell populations and cell-surface markers, or immunoassays for quantitative analysis of proteins and peptides.

Data quality assurance
Due to the nature of the study, only one on-site monitoring visit will be scheduled per center. The remaining support and management of study centers will occur by telephone contact and fax. On-site monitoring can and will occur in the event of a for cause need.
For source data verification, at least the following information must be included in the patient note / file : • Patient's demographic data.
• Date of patient's written informed consent, • the fact that the patient is in a study and the study number, • patient's visit dates, • serious adverse events, • adverse events, • confirmation of the diagnosis of the indication being treated, • concomitant medication and diseases, The CRA will collect the appropriate copy or copies of the completed forms. In addition, the CRA will determine whether all AEs and SAEs have been appropriately reported within the time periods required (SAEs only).
The study is exploratory in nature. No one particular variable can be designated as primary or secondary variable. The analyses of efficacy variables will be descriptive in nature for the NA cohort and where applicable for the NH cohort and the UK cohort of untreated patients. These variables include survival for the NA cohort, MS status as assessed by EDSS, MFSC and conversion to SPMS and any other relevant variable related to MS status. Also descriptive analyses will be provided for neuropsychological, HRQoL and resource use data, functional system scores, MRI parameters and health-related quality of life.
For the NA cohort, the descriptive analyses will also be stratified by the original clinical trial group assignment (low dose, high dose, and placebo). Time of exposure to Betaseron in the NA cohort will be determined appropriately and descriptive statistics will be provided based on time of exposure.
Comparison of the three cohorts based on selected characteristics will be performed descriptive after appropriate matching of the patients. Any comparison between the NA cohort and the UK cohort will be restricted to patients of the NA cohort that are alive.

Analysis of safety variables
The number and percentage of AEs will be presented by body system and intensity. Summary statistics (N, mean, standard deviation, minimum, lower quartile, median, upper quartile, and maximum) for each clinical laboratory variable assessed in the NA cohort will be presented.

Determination of sample size
Since this study is exploratory in nature and no one particular variable can be selected as primary variable, the determination of sample size is not applicable.
A total of 372 patients participated in Betaseron ® pivotal study (215 in the U.S. and 157 in Canada, cf. TT 5 below). Attempts will be made to obtain information about all patients and to examine as many patients as possible.

Independent Ethics Committee and Institutional Review Board
The study will commence only after the protocol has been approved by the appropriate Institutional Review Board (IRB) or Independent Ethics Committee (IEC) and written notification of the approval has been received by the Sponsor.
Neither the investigator nor the Sponsor will modify or alter this protocol without first obtaining the written agreement of the other. Alterations considered to be significant by the Sponsor's Core Clinician or by the investigator must be approved by the appropriate IEC/IRB prior to implementation, except where immediate implementation to eliminate an imminent hazard to the patient is necessary.
All protocol amendments that are agreed upon must be recorded on the standard Protocol Amendment Form, and must be signed and dated by both the Sponsor and the investigator.

Ethical conduct of the study
The planning and conduct of this clinical study are subject to national laws and the standard operating procedures for clinical investigation and documentation applicable in the Schering Group, including Berlex Laboratories. In the US, the study will be conducted in accordance with Good Clinical Practice (GCP) as required by 21 Code of Federal Regulations (CFR) Parts 50, 56 and 312. Compliance with these requirements also constitutes conformity with the ethical principles that have their origin in the Declaration of Helsinki and the International Conference on Harmonization (ICH)/GCP Guidelines of 17 Jan 1997.
At the discretion of the Sponsor's Core Clinician, the entire study may be cancelled for medical reasons. In addition, the Sponsor retains the right to end the study at any time if the study cannot be carried out as agreed upon in the study protocol. In case of premature termination the investigators, IRB/IECs and Regulatory Authorities will be informed by the Sponsor.

Patient information and consent
Attempts to contact patients who participated in the Betaseron ® pivotal study will be made only after the individual IRB/IECs grant waivers, where needed, allowing each study center to contact these patients for long-term follow-up (e.g., "HIPAA waiver" for the U.S.). Patients who agree to participate will be asked to sign an informed consent form. Different informed consent form will be used for each of the cohorts, because study activities differ for the study cohort and the untreated MS cohort.
The investigator will explain the nature of the study, its purpose and associated procedures, the expected duration and the potential benefits and risks of participation to each patient prior to his/her entry into the study (i.e. before examinations and procedures associated with selection for the study are performed). The information given will be based on a sample patient information and informed consent sheet provided by the Sponsor. The investigator will provide the patient with an IRB/IEC-approved patient information and informed consent form. Each patient will have ample opportunity to ask questions and will be informed about the right to withdraw from the study at any time without any disadvantage and without having to provide reasons for this decision.
Following this informative discussion a patient will be asked if he/she is willing to personally sign and date a statement of informed consent (general study). Only if the patient voluntarily agrees to sign the informed consent statement, and has done so, may he/she enter the study. The patient will receive a copy of his/her signed and dated form.
The informed consent statement is to remain in the investigator's files. The investigator will document on each CRF that he/she has informed the patient and that the patient has signed the informed consent statement.
If the patient is not capable of providing a signature, a verbal statement of consent can also be given in the presence of a witness. This is to be documented by a signature from the informing physician as well as by a signature from the witness. This procedure is subject to an explicit IRB/IEC approval.
The informed consent form and any other written information provided to patients will be revised whenever important new information becomes available that may be relevant to the patient's consent, or when there is an amendment to the protocol which necessitates a change to the content of the patient information and / or the written informed consent form. The investigator will inform the patient of changes in a timely manner and will ask the patient to confirm to continue his/her participation in the study by his/her signature on the revised informed consent form. Any revised written informed consent form and written information must receive the IRB/IEC's approval / favorable opinion in advance of use.
A sample informed consent form is part of the attachments to this protocol.

Data handling and record keeping
Data required according to this protocol are to be recorded on the CRFs provided by the Sponsor as soon as possible. Entries on the CRF must be made with a ballpoint pen and must be legible. Pencils and correction fluids may not be used.
If corrections are necessary they will be entered by an authorized member of the investigator's staff in the following manner: the wrong entry will be crossed out with a single line so that the text remains legible, and the correct entry will be placed next to it. Corrections will be initialed and dated.
Any documents related to the study must be archived at the study site or in a central archive. This includes the careful listing of the identities of the patients involved in the study. This list and the signed informed consent statements are key documents in the files to be stored by the investigator.
All documents related to the study must be retained until at least 15 years after the end of the study. At the end of this period, the Sponsor will inform the investigators as to when these documents no longer need to be retained.
Patient (hospital) files will be archived according to local regulations.

Drug accountability
Not applicable.

Financing
Funding for the study will be agreed between the investigator and the Sponsor and must be confirmed in writing before the study commences.

Financial disclosure
Each investigator (including the principal investigator and any subinvestigators) who is directly involved in the treatment or evaluation of research subjects must disclose certain financial arrangements. The following arrangements with, and interests of, investigators (including the spouse and dependent children) are disclosable to the FDA: • Compensation made to the investigator in which the value of compensation could be affected by study outcome (e.g., higher compensation for a favorable outcome than for an unfavorable outcome, or a royalty interest related to product sales); • A proprietary interest by the investigator in the tested product, including, but not limited to, a patent, trademark, copyright or licensing agreement; • Any equity interest in the Sponsor of this study, i.e., any ownership interest, stock options, or other financial interest whose value cannot be readily determined through reference to public prices, or any equity interest in a publicly held company that exceeds $ 50,000 in value held during the time the investigator is carrying out the study and for one year following completion of the study; • Significant payments of other sorts, i.e., payments that have a cumulative monetary value of $ 25,000 or more made by the Sponsor of a covered study to the investigator or the investigator's institution to support activities of the investigator exclusive of the costs of conducting the clinical study or other clinical studies, (e.g., a grant to fund ongoing research, compensation in the form of equipment or retainers for ongoing consultation or honoraria) during the time the investigator is carrying out the study and for 1 year following completion of the study.
In this context "investigator" is defined as all individuals listed on FDA form 1572 -or for non-IND studies performed outside the U.S. listed in the signature list -directly involved in the treatment or evaluation of research subjects. The term also includes the spouse and each dependent child of the investigator.
A financial disclosure statement must be provided to the Sponsor for each investigator (including each subinvestigator in IND studies identified on FDA Form 1572) at a study site before the study can commence. Financial disclosure statements must also be provided at the time the study is closed and at the 1-year anniversary of study closure.

Publication policy
It is intended to publish the results of the clinical trial in an accepted scientific journal. The Signatory Investigator (identified in Section 4.3), the Sponsor's Core Clinician, a representative of the MRI-AC, the Neuropsychological Auditor, and a representative of the Sponsor's Outcomes Research function will coordinate a joint publication. The Signatory Investigator will provide the main clinical publications and will review all other publications on any study results prior to their submission (e.g., separate publications on results of MRI or neuropsychological investigations or other fields of interest).
In order to give the Sponsor the opportunity to raise objections, all manuscripts including study results or parts of them must first be submitted to the Sponsor for review before any submission of any results or part of results to such scientific journal or any other journal or any publishing house will be made. The Sponsor will not unduly delay publication. All objections raised by the sponsor which are well-founded and not arbitrary will be considered.
A number of sub-studies have been proposed. These sub-studies will run under their own protocols with a separate informed consent. The provisions for publications outlined above do also apply to publications that the investigator intends to publish as a single center or in conjunction with a group of centers. However, this kind of publication may not be submitted before completion of the entire study and the submission of the principal publications.

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Manufacturer of the investigational product: No investigational product is given in this study.

Patient Information Leaflet for the study 308272
"A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis" Dear patient, You are being asked to consider if you would like to participate in this long-term follow-up study because you participated in one of the first research studies with Betaseron ® in relapsing-remitting multiple sclerosis (RRMS) approximately sixteen (16) years ago. This study led to the approval of the drug for use in RRMS by many governmental health protection authorities, among them the FDA and Health Canada. Therefore, the study is referred to as the "pivotal trial".
This new study is being sponsored by Berlex Pharmaceuticals, Inc. (Berlex) and is being managed by PPD Medical Communications (PPD). The following information describes the study and your role as a possible participant. Please read this information carefully and do not hesitate to ask any questions about the information provided.
To participate, you must have been previously enrolled in the Betaseron ® pivotal study that began in 1988, be willing to complete all study procedures and answer questions relating to your experiences with Multiple Sclerosis (MS). This study will include approximately seven (7) physicians in the United States and four (4) in Canada, and will enroll approximately 300 patients. In addition, approximately 60 patents who have never been treated for their MS will be enrolled in the United Kingdom. Your participation in this study will begin when you sign this consent and will end when Page 3 of 9 A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis   20 August 2004 you complete all study procedures. There is also a genetic sub-study planned. Your participation in this sub-study is optional and independent of participation in this study. Your doctor will discuss this sub-study with you separately.

Purpose
The purpose of this follow-up study is to systematically study the long-term course of the disease and possibly the long-term effectiveness of Betaseron ® by evaluating the patients that were previously enrolled in the pivotal study. In addition, these patients will be compared with the group of patients from the U.K. that have never received treatment for MS. Furthermore, characteristics of the course of the disease from the patients in the pivotal study will also be compared with those of a natural-history database composed of MS patients from Ontario who have not been treated for their disease.

Procedures
Participation in the study involves collecting data regarding your MS status. This data can be collected at one study visit or during several visits during a 21-day period after signing consent. The following procedures will be done: • Your doctor will ask you about your medical history that includes your general health, MS history, current status of your MS, information regarding the medications you have taken for your MS, and information about medications that may interfere with cognitive function. • Your doctor will perform a neurological examination and use three standardized tests, the Functional Systems Scores, Expanded Disability Status scale, and Multiple Sclerosis Functional Composite to assess your level of disability. • Your doctor will have you perform a series of cognitive tests to assess memory, learning, vision, attention, cognitive ability and language. These tests will take approximately 60-90 minutes to complete. The tests are available in English and French. If those languages are not your first language, you are invited to take the tests in one the provided versions, however your participation is strictly voluntary. You may decide not take the test in the provided versions. Not taking the tests will not affect the participation in the other parts of the study. • A Magnetic Resonance Imaging (MRI) scan will be performed, the quality of which will be assessed by a Central Analysis Center. If the quality of the MRI scan is not acceptable, you may have to undergo an additional MRI scan. • Laboratory Testing will include blood chemistry, hematology, thyroid panel, neutralizing antibodies against Betaseron ® , and immunological tests. The blood sample for immunological tests may be used for comparison with blood samples taken during the pivotal study. • You will be asked to complete four (4) questionnaires that ask your opinion of your health, mood, and the quality of your life. These questionnaires are available in English and French.
This will be the end of your obligations in this study. Some of these procedures may be done as part of your standard care even if you don't take part in this study. The study doctor or his staff can answer any questions you may have about the procedures that are not part of your standard care.

Risks and Discomforts
Blood samples will be taken and you might feel pain or light-headed from this. Further, the procedure has the usual risks coming with blood sampling, e.g., possible bleeding from the puncture site, bruising, pain, blood clot formation, or local infection and inflammation in the arm where the puncture was made (very rare cases). The amount of blood withdrawn during the study will be approximately 28 milliliters (approx. two tablespoons).
An MRI scan is a procedure that uses magnetic fields and radio waves (not x-rays) to take pictures of the brain. An MRI scan can be a noisy procedure, and some people may feel uncomfortable while lying in the scanner. People with pacemakers or certain other metallic implants may not undergo an MRI scan. In order for the scanner to detect areas of inflammation in your brain, a substance called gadolinium will be injected into your body through an intravenous (directly into your vein) line. Gadolinium can cause nausea, vomiting and slight warmth or pain at the injection site. Allergic reactions may also occur very rarely, and, in extremely rare instances, can be potentially serious. If you know that you have previously had a reaction to gadolinium, please be sure to inform your study doctor and you will not be required to undergo the MRI.
Participation in research may cause a loss of privacy. Berlex will do everything possible to ensure that information obtained from this study will never be inappropriately revealed to third parties. For further information on confidentiality, see Section "Confidentiality and authorization to use and disclose medical information" below.

Benefits
While there is no direct benefit associated with your participation in this study, it would provide your doctor with a profile of your experience with RRMS. With this and other information collected directly from this study, physicians may make more informed treatment decisions in the future for your care. By taking part in this registry study, you may contribute new information that may benefit other patients with MS in the future.

New Findings
You will be informed of any significant information regarding new findings that may develop during the course of the study that may relate to your willingness to continue.

Compensation for being part of this study
You will not be compensated for taking part in this study. You may discuss with your doctor or the study staff any questions about compensation.

Compensation or medical care for illness or injury
If you have an adverse reaction (get hurt or sick) as a direct result of properly performed procedures while taking part in this study, Berlex will pay your reasonable expenses for medical treatment of the reaction to the extent that these expenses are not covered by medical, third party, or government

Costs of participation
There is no cost to you or your insurance company to participate in this study. Your doctor will be paid a professional fee by Berlex for his/her help in conducting this study. You will still be responsible for the cost of your usual ongoing medical care, including procedures and/or non-study medications that your study doctor or regular doctor requires during this study as part of your usual medical care. If you have questions, please ask the study doctor or a member of the study staff.

Your participation is voluntary
Your participation is strictly voluntary. You may refuse to participate at any time during the course of this study without penalty or loss of benefits to which you are otherwise entitled. If you terminate your participation, you will continue to receive standard treatment and no prejudice will be shown towards you for medical care or participation in future studies. In addition, your participation may be ended by the study doctor or Berlex without your consent.
Berlex will pay you a stipend of US$ 250 (or an equivalent amount in Canadian dollar) to cover your travel expenses and to compensate you for the completion of the above mentioned four (4) questionnaires.

Alternatives
The study does not involve a treatment for any condition. Your alternative is to not participate.

Use of the data and data protection
Information obtained from the study will be electronically stored in an anonymous manner and processed for the purposes of scientific evaluation. Selected employees or representatives from the sponsor, representatives of governmental health protection authorities from your country or other countries (e.g. the FDA or Health Canada), and Ethics Committees or Institutional Review Boards (IRB) will be allowed to look at your study data and medical records in order to check that the study is being performed properly and that you have given your full informed consent (all of these individuals are bound to secrecy.) It will not be possible to identify you from any data from the study being sent to the study sponsor or licensing authorities, or from other data about illness collected by law. If the results of the study are published, your identity will remain confidential.

Confidentiality and authorization to use and disclose medical information
This section explains how your medical records and personal health information (together, your "records") will be used and disclosed for this study. "Personal health information" is information in your medical record that could be used to identify you, such as your name, address, telephone number, photographs, date of birth, social security number, prior medical records, or the types, dates, and results of various tests and procedures. Under federal law your study records cannot be used or disclosed by the study doctor for research purposes unless you sign this authorization. You may not participate in the study unless you sign this authorization. If you sign it, you will be agreeing to the disclosures below: • Your signature on this form allows the study doctor to disclose your records to the sponsor, Berlex Pharmaceuticals, Inc., or the sponsor's representatives. Berlex and its representatives will use the information to review the results of the study. Your study records will be assigned a code number by the study team and you will ordinarily not be identified by name in the study records that are sent to Berlex and its consultants. Any reports or publications resulting from this study will not disclose your identity. However, Berlex and its representatives will have the right to see your complete study records, including your name, and might choose to do so. Berlex and its representatives might review or copy all of your records to assure the quality of the study or for other uses allowed by law. • Personnel from Berlex and its representatives will be visiting the study doctor's office to check the conduct of the study, and they will be reviewing your medical records and your study records for this purpose. • All of your records and this signed consent form might be reviewed or copied by governmental health protection authorities (e.g., FDA or Health Canada, by <<your IRB>>, or by other regulatory agencies in this country and/or in other countries. These agencies might review your records to verify information collected in this study, to verify how the study is conducted, or for other uses allowed by law.
Federal and state laws require the study doctor to protect the confidentiality of your records. However, absolute confidentiality cannot be guaranteed because of the need to disclose information as described above. In addition, after the study doctor discloses your records, those laws may no longer protect the confidentiality of the information. If you would like to know how <<your IRB>> will protect the confidentiality of your records, you can contact <<your IRB>> at the telephone number listed below. If you would like to know how the Berlex and its representatives will protect the confidentiality of your records, ask your study doctor how to obtain this information.
You have the right to see and copy your records related to the study for 15 years following the completion of the study. However, by signing this form, you agree that you might not be able to review some of your records related to the study until after the study has been completed, at which time your right of access will be restored.
This authorization has no expiration date. You can cancel this authorization at any time by giving a written notice to the study doctor. If you cancel this authorization, then the study doctor will no longer use or disclose your records unless the study doctor needs to do so in order to preserve the scientific integrity of the study.
If you do not sign this form or if you cancel this authorization, then you no longer will be able to participate in the study.
If you decide to withdraw from the study early, you do not have to cancel your authorization to use and disclose your medical information. However, if you withdraw from the study and decide to cancel your authorization to use and disclose you medical information, the information that has already been collected in your study record may continue to be used and disclosed as described above, but only as necessary to protect the integrity of this study.

Questions and Contact
Take the time to understand this written information and the verbal explanations given by the study doctor or her/his staff. The study doctor or study staff will answer any questions you have about this study or your participation in the study.

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Manufacturer of the investigational product: No investigational product is given in this study.

Patient Information Leaflet for an additional pharmacogenetic study within the long-term follow-up study 308272
Dear Patient, Over the past few years there has been an enormous increase in our knowledge about the important role that genes play in a number of diseases. Genes are also known as 'family factors' or 'hereditary factors'. We also know that the genetic 'makeup' of individuals may influence the way they react to drugs, both in terms of wanted and unwanted effects of drugs.
The investigation of such relationships is a new research area known as pharmacogenetics. The aim of pharmacogenetics is to collect information about the relationship between genetic 'information' and the ability of a drug to influence a disease. By collecting genetic and clinical data from patients, it may be possible to discover genes that help to predict which patients are more likely to benefit from a drug, to select the best dose, and/or to avoid side effects.
You are currently participating or considering to participate in the long-term follow-up study for patients who were participating in one of the earliest studies of Betaseron ® in multiple sclerosis (MS). This study is sponsored by Berlex Pharmaceuticals, Inc ("Berlex"). Beside of the investigations described in the general patient information, we are planning to explore the relation between Betaseron ® , the course of disease in your case, and your genetic 'makeup'. We are inviting all patients participating in the study 308272 also to consider their participation in these additional pharmacogenetic analyses.
Only for patients having stopped to take Betaseron ® : Even if you may have stopped to take Betaseron ® some time ago -be it for side effects or other reasons -there might be valuable information to be gained from your participation in this additional exploration, e.g. to find out why you and others may had to stop taking the drug.

Why do this pharmacogenetic study?
A number of genes have already been identified that may contribute to the inheritance of MS, but so far no factors have been identified that predict the treatment response to Betaseron ® . It is still unclear why Betaseron ® works better in some patients than in others and why some patients suffer from more side effects than others. Neither is it known to what extent the natural course of the disease itself plays a role in this regard. The planned pharmacogenetic analyses may help to find answers to these questions.

What is happening in the pharmacogenetic study?
A small amount of genetic material (the so-called DNA) is needed. The genetic material will be isolated from blood cells. You will be asked to give an extra blood sample of about 12 mL (approx. one tablespoon). The blood will be taken together with the scheduled sampling for the study. It will be sent to a laboratory in a coded form (using your patient study-ID -not your name). There, the genetic material (DNA) will be stored for subsequent analyses. Before the analyses a second code will be given to the sample to exclude that somebody not authorized to do so could link the sample to you. Double coding is used also for all later analyses.
The planned pharmacogenetic analyses will examine those genes which • may be directly related to the development and/or severity of MS, or • may contribute to the biological effects of Betaseron ® and may influence the efficacy of the or may influence the occurrence of side effects.
As new knowledge about MS and Betaseron ® will become available, new genes may also be of significance for pharmacogenetic analyses. Therefore, the number of genes analyzed may vary from a few to a large number of genes depending on how much new knowledge will become available regarding your disease and Betaseron ® .
Your doctor has a list of the genes under study including their scientific names. If you are interested to see that list, please, request it from your study doctor. It is possible that Berlex may decide not to perform any pharmacogenetic analyses, for example if such an analyses are not justified by the clinical outcome of the trial. The destruction of the linking data and the subsequent anonymization will be verified by an external auditor.

Scope of results of the pharmacogenetic study
The planned analyses are basic research, so we do not expected that the results will yield any direct clinical applications. They will probably need to be verified in further studies. It is also unlikely that the results of the pharmacogenetic analyses will have any immediate impact on your treatment. Nevertheless, it is possible that additional information may be gained about the genetic characteristics that may be of importance to you individually: • information about MS that may be relevant for the prognosis or the treatment of your condition, • information about so far unknown or not diagnosed diseases other than MS, • information that may determine the safety of Betaseron ® and other similar drugs, • information that determine how Betaseron ® or similar drugs work in the body.
This means that genes may be found that are predictive of the future course of your disease and/or of the occurrence of other diseases. If such genes are found you will be given the option to be told about the findings by your study doctor or by any other doctor you may nominate (see also the paragraph on "Risks and Benefits"). You will be given that option of information also should findings emerge that may affect either the prognosis of patients taking Betaseron ® for a very long time, new treatment options, or the safety of Betaseron ® . You will be asked to consent to this option separately.
When deciding about the option to recieve that information, please consider the possible consequences and distress that such information may hold for you personally and (if you yourself decide to pass on such data) for your family, your work situation, or your health insurance plan. Please discuss this issue in detail with your study doctor.
The following procedure would be followed: We will notify the responsible study doctors of the findings without disclosing the results of any individual patient. If it can not be excluded that this information is relevant to your case, your study doctor will ask you whether or not you wish to be informed of your individual result. He will explain what clinical significance it may hold for you. Based on your own specific circumstances, you may then decide whether or not to request the information. Only then will your study doctor request your individual result from the central laboratory which will inform your designated contact person (your study doctor or another doctor, e.g., a geneticist) to fulfill your request.
If you want to be informed, it is important that you enable your study doctor to contact you, i.e., providing him with your current address and keeping this updated.

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A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 20 August 2004

Scientific and commercial use of the research findings
One day Berlex may be able to patent the results of this research project and publish the results in scientific journals and at conferences. These publications will not contain any personal information traceable to you. Any patents or other intellectual property that may result from this research project will become the sole property of Berlex (and its successors, licensees, and assigns) and may be used commercially, without any restrictions. This includes, for example, the development of a test to predict reactions to Betaseron ® , or the development of a new drug. This commercial interest may also be granted to other companies collaborating with Berlex. Any possible future commercial use does not imply that you will be remunerated in any way.

Risks and Benefits
You may know that the risk of misuse of data from genetic analyses is currently under public scrutiny. Berlex and the institutions contracted to store and analyze the pharmacogenetic samples have taken appropriate precautionary measures to prevent unauthorized access to your pharmacogenetic data. Detailed information is given in Section "11. Confidentiality of collected pharmacogenetic data and information". However, participation in research may cause a loss of privacy. Berlex will do everything possible to ensure that information obtained from this study will never be inappropriately revealed to you or any third party. For further information on confidentiality, see Section 11.
New knowledge may emerge from the pharmacogenetic analyses with respect to your disease and/or possible treatments. As said above: should you wish to be informed about such findings, it is essential that you consider the possible consequences that knowledge of such information may hold for you personally and for your family, your work situation, or your health insurance plan should you decide to pass on such data. Please discuss this issue in detail with your study doctor.
As mentioned above, the planned analyses are basic research, and it is not expected that the results will yield any direct clinical applications. For this reason, it is improbable that you will benefit directly from your participation in this pharmacogenetic study.

Discomfort
For you to take part in this additional investigation, we need a blood sample. We will take the sample as part of the regular blood sampling for the main study and therefore, no additional discomfort will be associated with the participation in this protocol. Otherwise, the procedure has the usual risks associated with blood sampling, e.g., possible bleeding from the puncture site, bruising, pain, blood clot formation, or local infection and inflammation in the arm where the puncture was made (very rare cases).

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A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 20 August 2004

Your participation is voluntary
Your participation in this additional pharmacogenetic analyses is voluntary. If you decide against participating in the additional pharmacogenetic study there will be no consequences in terms of your continued participation in the main clinical study nor for your subsequent medical treatment.

Alternatives
The study does not involve a treatment for any condition. Your alternative is to not participate.

Compensation for being part of this study
You will not be compensated for donating your blood sample. You may discuss with your doctor or the study staff any questions about compensation.

Costs of participation
You and/or your insurance company will not be expected to pay for any of the procedures or tests that are required as part of this study.

Compensation or medical care for illness or injury
If you have an adverse reaction (get hurt or sick) as a direct result of properly performed procedures while taking part in this study, Berlex will pay your reasonable expenses for medical treatment of the reaction to the extent that these expenses are not covered by medical, third party, or government insurance or programs. Appropriate medical treatment will be available, if required. For more information, please contact the study doctor or a member of the study staff.

Confidentiality of collected pharmacogenetic data and information
This section explains how the information of pharmacogenetic analyses will be generated, used, and disclosed in this study.. The general patient information (a separate document given to you by your study doctor) explains how your general (non-genetic) medical records and personal health information (together, your "records") will be used and disclosed for this study. "Personal health information" is information in your medical record that could be used to identify you, such as your name, address, telephone number, photographs, date of birth, social security number, prior medical records, or the types, dates, and results of various tests and procedures.
Confidentiality is of utmost importance to Berlex. Preventative security measures against potential disclosure of your personal information have been put in place. This means that your samples and data are unlikely to be traced back to you. For the samples that are not completely anonymized these include: • Your pharmacogenetic consent form will be archived by the study doctor separately from your other study documentation and your patient file. With the exception of the situations explained above, the results of your pharmacogenetic analyses will not be communicated to your study doctor or anybody else in the institution, and as such, will not appear in your patient file nor in any of the study data forms and will -as such -not be part of your records or personal health information. • The information obtained from this study will be electronically stored in an anonymous manner and processed for the purposes of scientific evaluation. The law requires that you need to consent explicitly to the blood sampling and the pharmacogenetic analyses described above to participate in the pharmacogenetic study. You will also need to consent that the results can be evaluated together with your data obtained in the study 308272. • The blood samples taken for pharmacogenetic analyses will be sent to a central laboratory in a coded form (your patient study-ID -not your name). For additional security, the pharmacogenetic test samples will be provided with a new, second code before processing. This second code will be applied at the latest before any analyses of the sample is performed and will then be used also for all pharmacogenetic data obtained. • Samples and all double-coded results of pharmacogenetic analyses will be stored in such a way as to prevent unauthorized access to the data. At the central laboratory storing your DNA only one person (and a deputy where applicable) will have access to a list linking the second code to your original patient ID (this is the first code -not your name). This person will not have access to any of your clinical data or your patient records. • Only a strictly limited number of persons, i.e., the person finally analyzing your pharmacogenetic data and his/her deputy will have access to your single-coded clinical data from your study records and the double-coded results of the analyses of your pharmacogenetic data. These persons are employees of Berlex or consultants of Berlex and are not part of the clinical study. They are pledged to a high degree of confidentiality.
Under federal law your study records cannot be used or disclosed for research purposes unless you sign this authorization. You may not participate in the study unless you sign this authorization. If you sign it, you will be agreeing to the disclosures below: • Your signature on this form allows the disclosure of your pharmacogenetic information to Berlex or it's representatives in the above described double-coded manner. Your samples and the information will be assigned a double-code number by the study team and the laboratory. You will not be identified by name in the records that are sent to Berlex and its consultants. Any reports or publications resulting from this study will not disclose your identity. • However, Berlex and its representatives will have the right to see your general (non-genetic) records, including your name, and might choose to do so. Personnel from Berlex and its representatives will be visiting the study doctor's office to check the conduct of the study, and they will be reviewing your medical records and your study records to assure the quality of the study or for other uses allowed by law. Berlex and its representatives might review or copy all of your records for this purpose. Double-coding will prevent the link between your records and the pharmacogenetic information. • All of your records -including the pharmacogenetic information and this signed consent formmight be reviewed or copied by governmental health protection authorities (e.g, FDA or Health Canada, by <<your IRB>>, or by other regulatory agencies in this country and/or in other countries. These agencies might review your records to verify information collected in this study, to verify how the study is conducted, or for other uses allowed by law.
Federal and state laws require the study doctor to protect the confidentiality of your records. However, absolute confidentiality cannot be guaranteed because of the need to disclose information as described above. In addition, after disclosure of your records, those laws may no longer protect the confidentiality of the information. If you would like to know how <<your IRB>> will protect the confidentiality of your records, you can contact <<your IRB>> at the telephone number listed below. If you would like to know how the Berlex and its representatives will protect the confidentiality of your records, ask your study doctor how to obtain this information.
You have the right to see and copy your records related to the study for 20 years following the completion of the study. As said above (see Section 4), you may want to consider the possible consequences that knowledge of such information may carry. By signing this form, you also agree that you might not be able to review some of your records related to the study until after the study has been completed, at which time your right of access will be restored.
Your authorization of the pharmacogenetic analyses will be limited in terms of time and scope. We ask you to consent to the storage and usage of your DNA sample for a period of 20 years after the end of this study (collection and verification of all data). After termination of this program, we will destroy your sample together with any resulting biological material and delete all individual results of pharmacogenetic analyses.
In addition to this limited use there is the possibility for extended use after complete anonymization of your sample. In such a case your sample and the data from the pharmacogenetic analyses will be completely anonymized and no link will be maintained to your clinical data from study 308272. The samples will only be linked to a few key data that will not allow the sample to be traced to you in any way. As a result, neither you nor anyone else will ever receive individual results of any further studies. The anonymization process is verified by an external auditor. You will be asked to consent to this option separately.
You can cancel this authorization at any time by giving a written notice to the study doctor. If you decide to cancel this authorization, please inform your study doctor, who will then inform the central laboratory to destroy your sample and all its isolated constituents. Berlex will then also erase all of your existing pharmacogenetic data from the data base. The only exception to this will be if your data or part of your data have already been included in a final evaluation of all patients or patient subgroups in the study. The data will not then be deleted from the larger data set, but we will exclude your data from all future analyses. If you do not sign this form or if you cancel this authorization, then you no longer will be able to participate in the study.
If you decide to withdraw from the study early, you do not have to cancel your authorization to use and disclose your medical information. However, if you withdraw from the study and decide to cancel your authorization to use and disclose you medical information, the information that has already been collected in your study record may continue to be used and disclosed as described above, but only as necessary to protect the integrity of this study.

Questions and contact
Take the time to understand this written information and the verbal explanations and information given by the study doctor. The study doctor or study staff will answer any questions you have about this study or your participation in the study.

Declaration of consent to an additional pharmacogenetic study within the long-term follow-up study 308272
To be stored seperately from the study records and patient file!

Patient No. (in study 308272): __ __ __ __
This "Declaration of Consent" is separate from and independent of the one you signed to take part in the study 308272. Please take the time to read the Patient Information Leaflet that describes the purpose of the pharmacogenetic analyses.
I have obtained my personal copy of the Patient Information Leaflet for additional pharmacogenetic analyses within the long-term follow-up study 308272. I have read and understood the Patient Information Leaflet.
I have had my questions answered after discussion with the doctor (signature below) regarding the nature, goals and course of the pharmacogenetic analyses. I was given sufficient time to make my decision. I understand that my participation in the pharmacogenetic analyses is voluntary and that my participation in the long-term follow-up study 308272 will not be affected if I decline to take part in this additional pharmacogenetic investigation.
I consent to having a blood sample of 12 mL taken for the pharmacogenetic analyses. This pharmacogenetic analyses will examine those of my genes which: • may be directly related to the development and/or severity of MS, or • may contribute to the biological effects of Betaseron ® and may influence the efficacy of the or may influence the occurrence of side effects.
I understand that the above listing limits the scope of the pharmacogenetic analyses. However, the number of genes to be analyzed may not be limited to the genes listed in the Patient Information Leaflet. I also understand with regard to the listing above that the number of genes to be studied in the future can vary from a few to a large number of genes depending on how much new knowledge will become available regarding my disease and Betaseron ® or related drugs. I also understand that the analyses may be performed outside of the United States or Canada.
I also agree to the evaluation and further use of my coded clinical data from the long-term follow-up study 308272 in connection with my coded pharmacogenetic data.
I reserve the right to withdraw my sample at any time and without suffering any disadvantage. I will not be asked to state the reasons for my decision. If I request withdrawal, my samples will be destroyed and I will be given the option to have any existing pharmacogenetic analyses data deleted. I understand that my pharmacogenetic data will not be erased once these data have already been entered into the overall evaluation of the long-term follow-up study 308272. I understand and agree that my consent to the pharmacogenetic analyses will be limited in terms of time and scope. It will remain valid for a period of 20 years after the end of this study, i.e., after collection and verification of all data. Thereafter my pharmacogenetic data will be deleted.
I agree to the complete anonymization of my sample or part of it. In such a case the link to my clinical data as documented for the study 308272 will be deleted. The samples will only be linked to a few key data that will not allow the sample to be traced back to me in any way. As a result, neither myself nor anyone else will ever receive personal results of any further studies. The anonymization process is verified by an external auditor. I understand that, in case of withdrawal of my consent, these pharmacogenetic sample cannot be destroyed as it is impossible to identify my individual sample after complete anonymization. I understand that the limitations in terms of scope of use and time of storage do not apply to samples kept in a completely anonymized form.

This statement requires a separate consent. Please, tick and initial one of the boxes below:
I agree to have parts or all of my pharmacogenetic sample kept in a completely anonymized form.

I do NOT want parts or all of my pharmacogenetic sample to be kept in a completely anonymized form.
I understand that results from the pharmacogenetic analyses will most likely need verification in additional trials. Therefore, I agree that under normal circumstances I will not be directly informed with regard to the general or individual results of the pharmacogenetic analyses. I understand that such findings may be of relevance to me once my individual data are retrieved. Such findings may concern links between my genetic make-up and Betaseron ® and/or genes relevant to the prognosis or the treatment of MS. They may also reveal the risk of another -so far non-diagnosed hereditary disease. If I want to be informed, Berlex will contact me via my study doctor. I understand that after my last visit related to this clinical trial it is my obligation to enable Berlex to contact me (e.g., by providing my study doctor with my current address).

This statement requires a separate consent. Please, tick and initial one of the boxes below:
I want to be informed by the study doctor of any scientifically validated results of the study in general and how these might affect me specifically.

I do NOT want to be informed by the study doctor of any scientifically validated results of the study in general and how these might affect me specifically.
I understand and agree that Berlex or other persons involved in this study may use any results commercially for future tests or drug development (e.g. patents). I understand that if I would have an adverse reaction as a direct result of properly performed procedures while taking part in this study, Berlex will pay my reasonable expenses for medical treatment of the reaction to the extent that these expenses are not covered by medical, third party, or government insurance or programs.
I agree to having the research results processed electronically, stored and exchanged in coded form between authorized persons as described in the Patient Information Leaflet.
I also agree that the health protection agencies of the governments in the US or Canada (e.g., the FDA or Health Canada) or of other countries and the competent IRB may be given access to both the pharmacogenetic information and clinical data, as well as to the code linking the second code with the original code and to this signed consent form.
I understand that information identifying me will be kept as confidential as possible and described in the Patient Information Leaflet and based on applicable laws and regulations. I understand also that absolute confidentiality cannot be guaranteed because of the need to provide information as described above.
By signing this form I have not given up any of my legal rights as a research participant. I understand that I will receive a copy of the Patient Information Leaflet and a signed copy of this consent form for my records.

Signature of patient:
Printed name of patient Date Signature In case of consent provided by a legal representative -signature of legal representative: (a) Basic elements of informed consent. In seeking informed consent, the following information shall be provided to each subject: (1) A statement that the study involves research, an explanation of the purposes of the research and the expected duration of the subject's participation, a description of the procedures to be followed, and identification of any procedures which are experimental.

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(2) A description of any reasonably foreseeable risks or discomforts to the subject.
(3) A description of any benefits to the subject or to others which may reasonably be expected from the research.
(4) A disclosure of appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the subject.
(5) A statement describing the extent, if any, to which confidentiality of records identifying the subject will be maintained and that notes the possibility that the Food and Drug Administration may inspect the records.
(6) For research involving more than minimal risk, an explanation as to whether any compensation and an explanation as to whether any medical treatments are available if injury occurs and, if so, what they consist of, or where further information may be obtained.
(7) An explanation of whom to contact for answers to pertinent questions about the research and research subjects' rights, and whom to contact in the event of a research-related injury to the subject. (8) A statement that participation is voluntary, that refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and that the subject may discontinue Page 3 of 3 A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 26 July 2004 participation at any time without penalty or loss of benefits to which the subject is otherwise entitled.
(b) Additional elements of informed consent. When appropriate, one or more of the following elements of information shall also be provided to each subject: (1) A statement that the particular treatment or procedure may involve risks to the subject (or to the embryo or fetus, if the subject is or may become pregnant) which are currently unforeseeable.
(2) Anticipated circumstances under which the subject's participation may be terminated by the investigator without regard to the subject's consent.
(3) Any additional costs to the subject that may result from participation in the research.
(4) The consequences of a subject's decision to withdraw from the research and procedures for orderly termination of participation by the subject.
(5) A statement that significant new findings developed during the course of the research which may relate to the subject's willingness to continue participation will be provided to the subject.
(6) The approximate number of subjects involved in the study.
(c) The informed consent requirements in these regulations are not intended to preempt any applicable Federal, State, or local laws which require additional information to be disclosed for informed consent to be legally effective.
(d) Nothing in these regulations is intended to limit the authority of a physician to provide emergency medical care to the extent the physician is permitted to do so under applicable Federal, State, or local law. The signatories declare • that they agree to conduct their responsibilities within the study in accordance with local law, the principles of the Declaration of Helsinki, ICH-GCP and the study protocol as presented • that they have acquainted themselves with the results of the pharmacological and toxicological trials of the investigational product and the results of other studies carried out to date • that they have read the study protocol and agree to it in its entirety

ACTION AND CLINICAL PHARMACOLOGY
Description BETASERON® (interferon beta-1b) is a purified, sterile, lyophilized protein product produced by recombinant DNA techniques and formulated for use by injection. Interferon beta-1b is manufactured by bacterial fermentation of a strain of Escherichia coli that bears a genetically engineered plasmid containing the gene for human interferon beta ser17 . The native gene was obtained from human fibroblasts and altered in a way that substitutes serine for the cysteine residue found at position 17. Interferon beta-1b is a highly purified protein that has 165 amino acids and an approximate molecular weight of 18,500 daltons. It does not include the carbohydrate side chains found in the natural material.

General
Interferons are a family of naturally occurring proteins, which have molecular weights ranging from 15,000 to 21,000 daltons. Three major classes of interferons have been identified: alpha, beta, and gamma. Interferon beta-1b, interferon alpha, and interferon gamma have overlapping yet distinct biologic activities. The activities of interferon beta are species-restricted and, therefore, the most pertinent pharmacological information on BETASERON (interferon beta-1b) is derived from studies of human cells in culture and in vivo.

Biologic Activities
Interferon beta-1b has been shown to possess both antiviral and immunomodulatory activities. The number of interferon-induced gene products (e.g., 2',5'-oligoadenylate synthetase, protein kinase, and indoleamine 2,3-dioxygenase) that are believed to be the mediators of the biological actions of interferon beta-1b. A number of these interferon-induced products have been readily measured in the serum and cellular fractions of blood collected from patients treated with interferon beta-1b.

Clinical Trials
The efficacy of 8 MIU BETASERON, administered subcutaneously every other day, has been studied in one placebo-controlled clinical trial in relapsing-remitting MS patients (n=124) and a placebo-controlled trial in secondary-progressive MS patients (n=360).

Relapsing-Remitting MS
The Patients who required more than three 28-day courses of corticosteroids were withdrawn from the study. Minor analgesics (e.g., acetaminophen), antidepressants, and oral baclofen were allowed ad libitum but chronic nonsteroidal anti-inflammatory drug (NSAID) use was not allowed.
The primary, protocol defined, outcome assessment measures were 1) frequency of exacerbations per patient and 2) proportion of exacerbation free patients. A number of secondary outcome measures were also employed as described in Table 1 In addition to clinical measures, annual magnetic resonance imaging (MRI) was performed and quantitated for extent of disease as determined by changes in total area of lesions. In a substudy of patients (n=52) at one site, MRIs were performed every 6 weeks and quantitated for disease activity as determined by changes in size and number of lesions.
Results at the protocol designated endpoint of 2 years (see TABLE 1  MRI data were also analyzed for patients in this study. A frequency distribution of the observed percent changes in MRI area at the end of 2 years was obtained by grouping the percentages in successive intervals of equal width. Figure 1 displays a histogram of the proportions of patients who fell into each of these intervals. The median percent change in MRI area for the 0.25 mg (8 MIU) group was -1.1% which was significantly smaller than the 16.5% observed for the placebo group (p=0.0001).
Fifty-two patients at one site had frequent MRI scans (every 6 weeks). The percentage of scans with new or expanding lesions was 29% in the placebo group and 6% in the 0.25 mg (8 MIU) treatment group (p=0.006).
MRI scanning is viewed as a useful means to visualize changes in white matter that are believed to be a reflection of the pathologic changes that, appropriately located within the lesions seen on MRI become foci of irreversible demyelinization (i.e., classic white matter plaques).
The prognostic significance of the MRI findings in this study has not been evaluated.
At the end of 2 years on assigned treatment, patients in the study had the option of continuing on treatment under blinded conditions. Approximately 80% of patients in each treatment group accepted. Although there was a trend toward patient benefit in the BETASERON groups during the third year, particularly in the 0.25 mg (8 MIU) group, there was no statistically significant difference between the BETASERON-treated vs. placebo-treated patients in exacerbation rate, or in any of the secondary endpoints described in Table 1. As noted above, in the 2-year analysis, there was a 31% reduction in exacerbation rate in the 0.25 mg (8 MIU) group, compared to placebo. The pvalue for this difference was 0.0001. In the analysis of the third year alone, the difference between treatment groups was 28%. The p-value was 0.065. The lower number of patients may account for the loss of statistical significance, and lack of direct comparability among the patient groups in this extension study make the interpretation of these results difficult. The third year MRI data did not show a trend toward additional benefit in the BETASERON arm compared with the placebo arm.
Throughout the clinical trial, serum samples from patients were monitored for the development of antibodies to interferon beta-1b. In patients receiving 0.25 mg (8 MIU) BETASERON (n=124) every other day, 45% were found to have serum neutralizing activity on at least one occasion. One third had neutralizing activity confirmed by at least two consecutive positive titres. This development of neutralizing activity may be associated with a reduction in clinical efficacy, although the exact relationship between antibody formation and therapeutic efficacy is not yet known.

Secondary-Progressive MS
The effectiveness of BETASERON administered subcutaneously at a dose of 0.25 mg (8 MIU) every other day for 3 years was studied in a European multicenter (32 sites), randomized, double-blind, placebo-controlled trial in patients with secondary-progressive MS.
The study included patients between 18 and 55 years of age who had clinically definite or laboratory-supported definite MS for not less than one year. Disease had to be in the secondary-progressive phase and deterioration could not be exclusively related to incomplete recovery from relapses. EDSS score at study entry was between 3.0 and 6.5 and patients had to have a history of at least two clearly identified relapses, or deterioration of at least 1 EDSS point (or 0.5 points between EDSS scores of 6.0 to 7.0) within the preceding 24 months. The primary efficacy endpoint was time to confirmed progression in disability, as determined by an increase by one point on the EDSS from baseline if the entry score was 3.0 to 5.5, or 0.5 points on the EDSS if the baseline score was 6.0 or 6.5. The increased score had to be maintained for three months before progression was confirmed. Secondary efficacy endpoints included time to becoming wheelchair-bound (EDSS 7.0) and annual relapse rate.
Although the study was designed with a treatment duration of three years, a prospectively planned interim analysis of efficacy was performed after all patients had completed 2 years in the study. This resulted in a decision by an independent Advisory Board to terminate the study early.
Approximately 85% of all EDSS data for the three year study duration were available for the interim analysis of the primary endpoint. The primary analysis of efficacy was based on all patients randomized to treatment (Intent to Treat). The primary statistical method for the primary endpoint was a non-parametric analysis of covariance with stratification for centre and adjustment for baseline EDSS. Results presented below are for the dataset at study termination.
During the study, assessment of the EDSS was performed by a physician not otherwise involved in the treatment of the patient. All EDSS physicians were regularly trained to guarantee a maximally standardized assessment of the EDSS. All efforts were undertaken to maintain the blinding, e.g., standard clothing to cover injection sites was obligatory. There was a statistically significant difference in time to confirmed progression in disability in favour of BETASERON (p=0.0046), as shown in Table 2. The delay in progression in disability became apparent after 9 months of treatment and was statistically significant from month 12 onwards.  Table 3). Although the proportion of male patients in the BETASERON group with confirmed progression in disability was slightly higher than that of female patients, piecewise logistic regression analysis did not reveal any significant treatment by gender interaction (p=0.4335).
Kaplan-Meier plots (post-hoc analysis) of the data are shown in Figure 2. In addition to clinical measures, annual magnetic resonance imaging (MRI) was performed.
All patients underwent a T2-weighted MRI scanning at baseline and yearly thereafter, while a subgroup of patients (Placebo, n = 61; BETASERON, n= 64) underwent monthly scans in months 1-6 and 19-24 in addition to the annual scans scheduled for the general study population. Results of secondary and tertiary MRI endpoints showed significant differences between treatment groups in favor of BETASERON (see Table 2). The exact relationship between MRI findings and the clinical status of patients is unknown.
Serum samples were collected throughout the study to test for the development of neutralizing antibodies (NAB) against interferon beta-1b. Analyses were performed to assess the association between NAB status (measured by an MxA neutralization assay) and treatment response as

WARNINGS
The administration of cytokines to patients with a pre-existing monoclonal gammopathy has been associated with the development of systemic capillary leak syndrome with shock-like symptoms and fatal outcome.
In Patients should be cautioned against the re-use of needles or syringes and instructed in safe disposal procedures. Information on how to acquire a puncture-resistant container for disposal of used needles and syringes should be given to the patient along with instructions for safe disposal of full containers.
Overall, 80% of patients in the two controlled clinical trials reported injection site reactions at one or more times during therapy. Post-marketing experience has been consistent with this finding, with infrequent reports of injection site necrosis.
The onset of injection site necrosis usually appears early in therapy with most cases reported to have occurred in the first two to three months of therapy. The number of sites where necrosis has been observed was variable.
Rarely, the area of necrosis has extended to subcutaneous fat or fascia. Response to treatment of injection site necrosis with antibiotics and/or steroids has been variable. In some of these patients elective debridement and, less frequently, skin grafting took place to facilitate healing which could take from three to six months.
Some patients experienced healing of necrotic skin lesions while BETASERON therapy continued.
In other cases new necrotic lesions developed even after therapy was discontinued.
The nature and severity of all reported reactions should be carefully assessed. Patient understanding and use of aseptic self-injection technique and procedures should be periodically reevaluated.
Flu-like symptoms are not uncommon following initiation of therapy with BETASERON. In the controlled MS clinical trials, acetaminophen was permitted for relief of fever or myalgia.
Patients should be cautioned not to change the dosage or the schedule of administration without medical consultation. Patients should be cautioned to report depression or suicidal ideation (see WARNINGS).

Awareness of Adverse Reactions
Patients should be advised about the abortifacient potential of BETASERON (see PRECAUTIONS, Use in Pregnancy).

Laboratory Tests
The following laboratory tests are recommended prior to initiating BETASERON therapy and at periodic intervals thereafter: thyroid function test, hemoglobin, complete and differential white blood cell counts, platelet counts and blood chemistries including liver function tests. A pregnancy test, chest roentgenogram and ECG should also be performed prior to initiating BETASERON therapy.
In the controlled MS trials, patients were monitored every 3 months. The study protocol stipulated that BETASERON therapy be discontinued in the event the absolute neutrophil count fell below 750/mm 3  Similarly, if AST/ALT (SGOT/SGPT) levels exceeded 10 times the upper limit of normal, or if the serum bilirubin exceeded 5 times the upper limit of normal, therapy was discontinued. In each instance during the controlled MS trial, hepatic enzyme abnormalities returned to normal following discontinuation of therapy. When measurements had decreased to below these levels, therapy could be restarted at a 50% dose reduction, if clinically appropriate. Dose was reduced in two patients due to increased liver enzymes; one continued on treatment and one was ultimately withdrawn.

Drug Interactions
Interactions

Nursing Mothers
It is not known whether BETASERON is excreted in human milk. Given that many drugs are excreted in human milk, there is a potential for serious adverse reactions in nursing infants, therefore a decision should be made whether to discontinue nursing or discontinue BETASERON treatment.

Pediatric Use
Safety and efficacy in children under 18 years of age have not been established.

Dependence Liability
No evidence or experience suggests that abuse or dependence occurs with BETASERON therapy; however, the risk of dependence has not been systematically evaluated.   It should be noted that the figures cited in Table 4 cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. The cited figures do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the side effect incidence rate in the population studied.

Secondary-progressive MS
The incidence of adverse events that occurred in at least 2% of patients treated with 8 MIU BETASERON or placebo for up to three years, or where an adverse event was reported at a frequency at least 2% higher with BETASERON than that observed for placebo-treated patients in the secondary-progressive study, is presented in Table 5.
Adverse events significantly associated with BETASERON compared to placebo (p<0.05) are also indicated in Table 5.     Seventy-four (74)

SAFETY TIPS
Use only the supplies that come with your Betaseron package.
Use only the diluent from the pre-filled syringe.
Wash your hands thoroughly with soap and water before starting.
Keep the items sterile. Do not touch the needle, the piercing spike of the vial adapter or the top of the cleaned vial.
Make sure none of the items in your package have been opened or are damaged.
Do not reuse opened materials. Throw away any unused portions of Betaseron and diluent.
Throw away used syringes and needles in the proper disposal container.

STEP 1: CHOOSING AN INJECTION SITE
BETASERON should be injected into subcutaneous tissue (under the skin, between the fat layer and the muscles beneath). The best areas for injection are loose and soft, away from joints.
Choose an injection site from the following areas: Abdomen, above the waistline (at least 5 cm on either side of the navel) Right thigh (at least 5 cm above the knee and 5 cm below the groin) Wash your hands thoroughly with soap and water.

3.
Open the pack by peeling off the label.

4.
Take out all the contents.

NOTE: Be sure the vial adapter blister pack is sealed and the rubber cap is firmly attached
to the diluent syringe.

5.
Check the expiry date on the Betaseron vial and the pre-filled diluent syringe.  6. Turn the single-use pack over, place the Betaseron vial in the well (vial holder) in the centre of the pack and place the pre-filled diluent syringe in the U-shaped trough.

1.
Remove the Betaseron vial from the vial holder and take the protective cap off the vial.

2.
Place the vial back into the vial holder.

3.
Use an alcohol wipe to clean the top of the vial. Move the wipe in one direction.

NOTE:
Leave the alcohol wipe on top of the vial until step 5.

4.
Peel off the vial adapter blister pack label but do not remove the vial adapter.

NOTE:
Be sure to avoid touching the vial adapter, in order to maintain its sterility.

8.
It is important to slowly push the plunger of the diluent syringe all the way in. This will transfer all of the diluent into the Betaseron vial ( Figure 3). The plunger may return to its original position after release.

9.
With the syringe assembly attached, swirl the vial gently to completely dissolve the white cake of Betaseron. (DO NOT SHAKE.)

10.
Look closely at the Betaseron solution for particles. It should be clear.

NOTE:
If the mixture contains particles or is discoloured, discard it and start again.

2.
Slowly pull the plunger back to withdraw the entire contents of the Betaseron vial into the syringe (Figure 4).

NOTE: If 1 mL of clear solution cannot be withdrawn from the vial, discard the vial and
syringe and start over.

3.
Turn the syringe assembly so that the needle end is pointing up. Remove any air bubbles (you may gently tap the outer wall of the syringe to free any bubbles) by slowly pushing the plunger to the 1 mL mark on the syringe.

NOTE:
If too much solution is expelled into the vial, repeat steps 1, 2 and 3.

4.
Remove the vial adapter and the vial from the syringe by twisting the vial adapter as shown in Figure 5. This will release the vial adapter, with the vial, from the syringe but leave the needle on the syringe ( Figure 5).

5.
You have now reconstituted your Betaseron and are ready to be injected. The injection should be administered immediately after mixing. If you are unable to give the injection immediately, you may refrigerate the medication in the syringe and inject within three hours. Do not freeze.

1.
Use a fresh alcohol wipe to clean the skin at the injection site. Use a circular motion from the centre of the injection site outward. Let the alcohol dry.

2.
Throw away the wipe.

3.
Remove the protective needle guard from the needle by pulling it without turning.

4.
Gently pinch the skin around the site to lift it up a bit.

5.
Stick the needle straight into the skin at a 90° angle with a quick, firm motion.

6.
Inject the drug by using a slow, steady push (push the plunger all the way in until the syringe is empty).

7.
Remove the needle from the skin.

8.
Gently massage the injection site with a fresh alcohol wipe.

Directives pour l'auto-administration
Il faut aviser les patients de ne pas modifier la dose ou la fréquence d'administration sans avoir préalablement consulté leur médecin.
Attendez au moins une semaine avant de faire une autre injection au même endroit. MAGNEVIST ® Injection has a pH of 6.5 to 8.0. Pertinent physicochemical data are noted below: and pH7 log P w = -5.4 MAGNEVIST ® Injection has an osmolality 6.9 times that of plasma which has an osmolality of 285 mOsmol/kg water. MAGNEVIST ® Injection is hypertonic under conditions of use.

Pharmacokinetics
The pharmacokinetics of intravenously administered gadopentetate dimeglumine in normal subjects conforms to a two compartment open-model with mean distribution and elimination half-lives (reported as mean ± SD) of about 0.2 ± 0.13 hours and 1.6 ± 0.13 hours, respectively.
Upon injection, the meglumine salt is completely dissociated from the gadopentetate dimeglumine complex. Gadopentetate is exclusively eliminated in the urine with 83 ± 14% (mean ± SD) of the dose excreted within 6 hours and 91 ± 13% (mean ± SD) by 24 hours, post-injection. There was no detectable biotransformation or decomposition of gadopentetate dimeglumine.
The renal and plasma clearance rates (1.76 ± 0.39 mL/min/kg and 1.94 ± 0.28 mL/min/kg, respectively) of gadopentetate are essentially identical, indicating no alteration in elimination kinetics on passage through the kidneys and that the drug is essentially cleared through the kidney. The volume of distribution (266 ± 43 mL/kg) is equal to that of extracellular water and clearance is similar to that of substances which are subject to glomerular filtration.
In vitro laboratory results indicate that gadopentetate does not bind to human plasma protein. In vivo protein binding studies have not been done.

Pharmacodynamics
Gadopentetate dimeglumine is a paramagnetic agent and, as such, it develops a magnetic moment when placed in a magnetic field. The relatively large magnetic moment produced by the paramagnetic agent results in a relatively large local magnetic field, which can enhance the relaxation rates of water protons in the vicinity of the paramagnetic agent.
In magnetic resonance imaging (MRI), visualization of normal and pathological brain tissue depends in part on variations in the radiofrequency signal intensity that occur with 1) changes in proton density; 2) alteration of the spin-lattice or longitudinal relaxation time (T1); and 3) variation of the spin-spin or transverse relaxation time (T2). When placed in a magnetic field, gadopentetate dimeglumine decreases the T1 and T2 relaxation time in tissues where it accumulates. At usual doses the effect is primarily on the T1 relaxation time.
Gadopentetate dimeglumine does not cross the intact blood-brain barrier and, therefore, does not accumulate in normal brain or in lesions that do not have an abnormal blood-brain barrier, e.g., cysts, mature post-operative scars, etc. However, disruption of the blood-brain barrier or abnormal vascularity allows accumulation of gadopentetate dimeglumine in lesions such as neoplasms, abscesses, and subacute infarcts. The pharmacokinetic parameters of MAGNEVIST ® in various lesions are not known.

CLINICAL TRIALS
MAGNEVIST ® Injection was administered to 1272 patients in open label controlled clinical studies. The mean age of these patients was 46.4 years (range 2 to 93 years). Of these patients, 55% (700) were male and 45% (572) were female. Of the 1271 patients who received MAGNEVIST ® Injection and for whom race was reported, 82.1% (1043) were Caucasian, 9.7% (123) were Black, 5.3% (67) were Hispanic, 2.1% (27) were Oriental/Asian, and 0.9% (11) were other. Of the 1272 patients, 550 patients were evaluated in blinded reader studies. These evaluated the use of contrast enhancement in magnetic resonance imaging of lesions in the head and neck, brain, spine and associated tissues, and body (excluding the heart). Of the 550 patients, all patients had a reason for an MRI and efficacy assessments were based on pre-and post-MAGNEVIST ® injection film quality, film contrast, lesion configuration (border, size, and location), and the number of lesions. The protocols did not include systematic verification of specific diseases or histopathologic confirmation of findings.
Of the above 550 patients, 97 patients received 0.1 mmol/kg MAGNEVIST ® Injection I.V. in two clinical trials of MAGNEVIST ® MRI contrast enhancement for body imaging. Of these 97, 68 had MRIs of the internal organs/structures of the abdomen or thorax (excluding the heart); 8 had breast images and 22 had images of appendages. The results of MRIs before and after MAGNEVIST ® use were compared blindly. Overall additional lesions were identified in 22/97 (23%) of the patients after MAGNEVIST ® Injection. The mean number of lesions identified before (1.49/patient) and after MAGNEVIST ® (1.75/patient) were similar. Seven (8%) of the patients had lesions seen before MAGNEVIST ® that were not seen after MAGNEVIST. ® Overall, after MAGNEVIST ® Injection, 41% of the images had a higher contrast score than before injection; and 18% of the images had a higher contrast score before MAGNEVIST ® Injection than after MAGNEVIST ® Injection. MAGNEVIST ® MRI of the 8 patients with breast images were not systematically compared to the results to mammography, breast biopsy or other modalities. In the 22 patients with appendage images (e.g., muscle, bone and intraarticular structures), MAGNEVIST ® MRI was not systematically evaluated to determine the effects of contrast biodistribution in these different areas.
Of the above 550 patients, 66 patients received MAGNEVIST ® 0.1 mmol/kg I.V. in clinical trials of MAGNEVIST ® MRl contrast enhancement of lesions in the head and neck. A total of 66 MRI images were evaluated blindly by comparing each pair of MRI images, before and after MAGNEVIST ® Injection. In these paired images, 56/66 (85%) had greater enhancement after MAGNEVIST ® and 40/66 (61%) had better lesion configuration or border delineation after MAGNEVIST. ® Overall, there was better contrast after MAGNEVIST ® in 55% of the images, comparable enhancement in 44 (36%) before and after MAGNEVIST, ® and better enhancement in 9% without MAGNEVIST. ® In the studies of the brain and spinal cord, MAGNEVIST ® 0.1 mmol/kg I.V. provided contrast enhancement in lesions with an abnormal blood brain barrier.
In two studies, a total of 108 patients were evaluated to compare the dose response effects of 0.1 mmol/kg and 0.3 mmol/kg of MAGNEVIST ® in CNS MRI. Both dosing regimens had similar imaging and general safety profiles; however, the 0.3 mmoL/kg dose did not provide additional benefit to the final diagnosis (defined as number of lesions, location and characterization).

Central Nervous System:
MAGNEVIST ® Injection is indicated for use with magnetic resonance imaging (MRI) in adults, and pediatric patients (2 years of age and older) to visualize lesions with abnormal vascularity in the brain (intracranial lesions), spine and associated tissues. MAGNEVIST ® Injection has been shown to facilitate visualization of intracranial lesions including but not limited to tumors.

Extracranial/Extraspinal Tissues:
MAGNEVIST ® is indicated for use with MRI in adults and pediatric patients (2 years of age and older) to facilitate the visualization of lesions with abnormal vascularity in the head and neck.

Body:
MAGNEVIST ® Injection is indicated for use in MRI in adults and pediatric patients (2 years of age and older) to facilitate the visualization of lesions with abnormal vascularity in the body (excluding the heart).

CONTRAINDICATIONS
None. Patients with other hemolytic anemias have not been adequately evaluated following administration of MAGNEVIST ® Injection to exclude the possibility of increased hemolysis.

WARNINGS
Hypotension may occur in some patients after injection of MAGNEVIST ® Injection. In clinical trials two cases were reported and in addition, there was one case of vasovagal reaction and two cases of pallor with dizziness, sweating and nausea in one and substernal pain and flushing in the other. These were reported within 25 to 85 minutes after injection except for the vasovagal reaction which was described as mild by the patient and occurred after 6-1/2 hours. In a study in normal volunteers one subject experienced syncope after arising from a sitting position two hours after administration of the drug. Although the relationship of gadopentetate dimeglumine to these events is uncertain, patients should be observed for several hours after drug administration.
Patients with a history of allergy, drug reactions, or other hypersensitivity-like disorders, should be closely observed during the procedure and for several hours after drug administration. (See PRECAUTIONS -General.)

PRECAUTIONS -General
As with various other injectable products, cases of phlebitis and thrombophlebitis have been reported also in association with MAGNEVIST ® Injection. In most cases, symptoms presented during or shortly after injection, and generally within 24 hours of injection and responded to supportive treatment. However, in very rare cases of patients who may have underlying potential to develop thrombotic syndromes, thrombosis with fasciitis and surgical intervention (e.g., compartment release or amputation) of the dosed limb have been reported. The relationship of these events to pre-existing disease, concomitant medications, preexisting vascular fragility, MAGNEVIST ® Injection, or the injection procedure was not established. Patency and integrity of the intravenous line should be determined before administration. As with other intravenous injections, appropriate surveillance of the dosing limb for the development of local injection site reactions following administration of MAGNEVIST ® Injection is recommended. Diagnostic procedures that involve the use of contrast agents should be carried out under direction of a physician with the prerequisite training and a thorough knowledge of the procedure to be performed.

AS
In a patient with a history of grand mal seizure, MAGNEVIST ® Injection was reported to induce such a seizure.
Since gadopentetate dimeglumine is cleared from the body by glomerular filtration, caution should be exercised in patients with impaired renal function. MAGNEVIST ® is not significantly eliminated by the hepatobiliary enteric pathway, but is dialyzable (See Pharmacodynamics Section). Caution should be exercised in patients with either renal or hepatic impairment.
The possibility of a reaction, including serious, life-threatening, or fatal anaphylactoid or cardiovascular reactions or other idiosyncratic reactions (see ADVERSE REACTIONS), should always be considered, especially in those patients with a known clinical hypersensitivity or a history of asthma or other allergic respiratory disorders.
Animal studies suggest that gadopentetate dimeglumine may alter red cell membrane morphology resulting in a slight degree of extravascular (splenic) hemolysis. In clinical trials 15-30% of the patients experienced an asymptomatic transient rise in serum iron. Serum bilirubin levels were slightly elevated in approximately 3.4% of patients. Levels generally returned to baseline within 24 to 48 hours. Hematocrit and red blood cell count were unaffected and liver enzymes were not elevated in these patients. While the effects of gadopentetate dimeglumine on serum iron and bilirubin have not been associated with clinical manifestations, the effect of the drug in patients with hepatic disease is not known and caution is therefore advised.
When MAGNEVIST ® Injection is to be injected using nondisposable equipment, scrupulous care should be taken to prevent residual contamination with traces of cleansing agents. After MAGNEVIST ® Injection is drawn into the syringe the solution should be used immediately.
Repeat Procedures: Data for repeated procedures are not available. If in the clinical judgment of the physician sequential or repeat procedures are required, a suitable interval of time between administrations should be observed to allow for normal clearance of the drug from the body.

Repeat Injections: (See DOSAGE AND ADMINISTRATION)
Information for Patients: Patients scheduled to receive MAGNEVIST ® Injection should be instructed to inform their physician if the patient: 1. Is pregnant or breast feeding.
2. Has any blood disorders; i.e., anemia, hemoglobinopathies, or diseases that affect red blood cells.
3. Has a history of renal or hepatic disease, seizure, asthma or allergic respiratory disorders.

LABORATORY TEST FINDINGS
Transitory changes in serum iron, bilirubin and transaminase levels have been reported in patients with normal and abnormal liver function (See PRECAUTIONS -General).

CARCINOGENESIS, MUTAGENESIS AND IMPAIRMENT OF FERTILITY
Long term animal studies have not been performed to evaluate the carcinogenic potential of gadopentetate dimeglumine.
A comprehensive battery of in vitro and in vivo studies in bacterial and mammalian systems suggest that gadopentetate dimeglumine is not mutagenic or clastogenic and does not induce DNA repair in rat hepatocytes or cause cellular transformation of mouse embryo fibroblasts. A dominant lethal effect on early spermatids was demonstrated in vivo in the mouse in one study after intravenous administration of 6 mmol/kg but was not verified in a follow up study.
When administered intra-peritoneally to male and female rats daily prior to mating, during mating and during embryonic development for up to 74 days (males) or 35 days (females), gadopentetate caused a decrease in number of corpora lutea at the 0.1 mmol/kg dose level. After daily dosing with 2.5 mmol/kg suppression of food consumption and body weight gain (males and females) and a decrease in the weights of testes and epididymis were also observed.
In a separate experiment in rats, daily injections of gadopentetate dimeglumine over 16 days caused spermatogenic cell atrophy at a dose level of 5 mmol/kg but not at a dose level of 2.5 mmol/kg. This atrophy was not reversed within a 16-day observation period following the discontinuation of the drug.

PREGNANCY CATEGORY C.
Gadopentetate dimeglumine retarded fetal development slightly when given intravenously for 10 consecutive days to pregnant rats at daily doses of 0.25, 0.75, and 1.25 mmol/kg ( 2.5, 7.5 and 12.5 times the human dose based on body weight) and when given intravenously for 13 consecutive days to pregnant rabbits at daily doses of 0.75 and 1.25 mmol/kg (7.5 and 12.5 times the human dose respectively, based on body weight) but not at daily doses of 0.25 mmol/kg. Congenital anomalies were noted in rats or rabbits.
Adequate and well controlled studies were not conducted in pregnant women. MAGNEVIST ® Injection should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

NURSING WOMEN
C 14 labelled gadopentetate dimeglumine was administered intravenously to lactating rats at a dose of 0.5 mmol/kg. Less than 0.2% of the total dose was transferred to the neonate via the milk during the 24-hour evaluation period. It is not known to what extent MAGNEVIST ® Injection is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when MAGNEVIST ® Injection is administered to a nursing woman.

PEDIATRIC USE
The

ADVERSE REACTIONS
The mean age of the 1272 patients who received MAGNEVIST ® Injection was 46.4 years (range 2 to 93 years). Of these patients, 55% (700) were male and 45% (572) were female. Of the 1271 patients who received MAGNEVIST ® Injection and for whom race was reported, 82.1% (1043) were Caucasian, 9.7% (123) were Black, 5.3% (67) were Hispanic, 2.1% (27) were Oriental/Asian, and 0.9% (11) were other. The most common noted adverse event is headache with an incidence of 4.8%. The majority of headaches are transient and of mild to moderate severity. Nausea is the second most common adverse experience at 2.7%. Injection site coldness/localized coldness is the third most common adverse experience at 2.3%. Dizziness occurred in 1% of the patients.
The following additional adverse events occurred in fewer than 1% of the patients: Body as a Whole: Injection site symptoms, namely, pain, localized warmth, and burning sensation; substernal chest pain, back pain, fever, weakness, generalized coldness, generalized warmth, localized edema, tiredness, chest tightness, trembling, shivering, tension in extremities, regional lymphangitis, pelvic pain, and anaphylactoid reactions (characterized by cardiovascular, respiratory and cutaneous symptoms) rarely resulting in death.

OVERDOSAGE
Systemic consequences associated with overdosage of MAGNEVIST ® Injection have not been reported.

DOSAGE AND ADMINISTRATION
The recommended dosage of MAGNEVIST ® Injection is 0.2 mL/kg (0.1 mmol/kg) administered intravenously, at a rate not to exceed 10 mL per 15 seconds. Dosing for patients in excess of 286 lbs have not been studied systematically.
Drug Handling: To ensure complete injection of the contrast medium, the injection should be followed by a 5-mL normal saline flush. The imaging procedure should be completed within 1 hour of injection of MAGNEVIST ® Injection.
As with other gadolinium contrast agents, MAGNEVIST ® Injection has not been established for use in magnetic resonance angiography.
Parenteral products should be inspected visually for particulate matter and discoloration prior to administration. Do not use the solution if it is discolored or particulate matter is present.
Any unused portion must be discarded in accordance with regulations dealing with the disposal of such materials.

HOW SUPPLIED
MAGNEVIST ® Injection is a clear, colorless to slightly yellow solution containing 469.01 mg/mL of gadopentetate dimeglumine in rubber stoppered vials. MAGNEVIST ® Injection is supplied in the following sizes:

Therapeutic Classification
Contrast Enhancement Agent for Magnetic Resonance Imaging (MRI)

ACTION AND CLINICAL PHARMACOLOGY
MAGNEVIST (gadopentetate dimeglumine) was developed as a contrast agent for diagnostic use in magnetic resonance imaging (MRI). Gadolinium is a rare earth element.
Its ion (Gd +++ ) has seven unpaired electrons and, therefore, shows paramagnetic properties. Gd +++ has a strong effect on the hydrogen-proton spin-lattice relaxation time (T 1 ), which causes the observed contrast enhancement in MRI scans. By chelation of Gd +++ with diethylenetriamine pentaacetic acid (DTPA), a strongly paramagnetic, welltolerated, stable complex (gadopentetate dimeglumine salt) is obtained.
The free gadolinium ion is unsuitable for clinical use due to high toxicity, however, the metal chelate is metabolically inert. The organic component of the chelate is not measurably metabolized and the metal does not dissociate. After intravenous injection of gadopentetate dimeglumine, the meglumine ion completely dissociates from the gadopentetate. The hydrophilic chelate is distributed only in the extracellular water and does not cross the intact blood-brain barrier. Gadopentetate is excreted unchanged in the urine. It is rapidly eliminated by the kidneys with a clearance identical to that of inulin (no tubular reabsorption). There was no detectable biotransformation, dissociation or decomposition of gadopentetate.
MAGNEVIST has no pharmacodynamic effect when administered as indicated with the exception of slightly increased plasma osmolality.

INDICATIONS AND CLINICAL USE
MAGNEVIST (gadopentetate dimeglumine), by intravenous injection, is indicated for contrast enhancement during cranial and spinal MRI investigations in adults and children, to detect lesions associated with abnormal vascularity, or those thought to alter the bloodbrain barrier.
MAGNEVIST is also indicated for use with MRI in adults to provide contrast enhancement and facilitate visualization of lesions with abnormal vascularity within the head (extracranial) and neck.

CONTRAINDICATIONS
MAGNEVIST (gadopentetate dimeglumine) should not be administered to patients who are known or suspected of being hypersensitive to it.

WARNINGS
The decision to use MAGNEVIST (gadopentetate dimeglumine) must be made after careful evaluation of the risk-benefit in patients with a history of allergic disposition or bronchial asthma, since experience shows that these patients suffer more frequently than others from hypersensitivity reactions.
In very rare cases anaphylactoid reactions, including anaphylactic shock, may occur after intravenous injection of MAGNEVIST. It is important for prompt action in the event of such incidents to be familiar with the practice of emergency measures. To permit immediate counter-measures to be taken in emergencies, appropriate drugs and instruments (e.g. endotracheal tube and ventilator) should be readily available. No studies have been conducted in children with severe renal or hepatic dysfunction, clinically unstable or uncontrolled hypertension, or in premature infants.
MRI procedures which involve the use of MAGNEVIST by injection should be carried out by physicians who have the prerequisite training and a thorough knowledge of the particular procedure to be performed.

General
MAGNEVIST (gadopentetate dimeglumine) is to be administered strictly by intravenous injection. MAGNEVIST will cause tissue irritation and pain if administered extravascularly or if it leaks interstitially.
A sweet taste may be experienced briefly by patients receiving a bolus injection of MAGNEVIST intravenously.

Hemolytic States
Gadopentetate dimeglumine alters red blood cell morphology resulting in transient, slight, extravascular (splenic) hemolysis with increased serum iron and total bilirubin levels.
Although this effect was of no clinical significance during clinical trials, caution is advised in patients with hepatic disease and/or hemolytic states.

Convulsive States
While there is no evidence suggesting that MAGNEVIST directly precipitates convulsion, the possibility that it may decrease the convulsive threshold in susceptible patients cannot be ruled out. Precautionary measures should be taken with patients predisposed to seizure, e.g. close monitoring and availability of injectable anticonvulsants (see DOSAGE

Pregnancy
There are no studies on the use of MAGNEVIST in pregnant women. MAGNEVIST should not be used during human pregnancy unless the potential benefit justifies the potential risk to the fetus.

Nursing Mothers
Transfer of MAGNEVIST into the milk of lactating mothers can occur. Thus breast feeding should be interrupted for 24 hours post administration of MAGNEVIST and the milk discarded during this period.

Use in the Elderly
No special precautions are required for elderly patients.

General
Most adverse reactions to MAGNEVIST (gadopentetate dimeglumine) develop soon after injection, however the possibility of delayed reactions cannot be ruled out. The most frequently reported adverse reactions following administration of MAGNEVIST were: Convulsions were reported in 4 patients with a history of seizures.

Laboratory Changes
Reversible mild elevations over baseline in serum iron and total bilirubin occur in most patients after receiving MAGNEVIST. These changes do not appear to be clinically relevant. Other disturbances in laboratory values (transient increases in liver function tests) have not been associated with the use of MAGNEVIST.

Adverse Drug Reaction Profile
The following adverse reactions, listed according to body system, have been reported after administration of MAGNEVIST:

SYMPTOMS AND TREATMENT OF OVERDOSAGE
In the event of inadvertent overdosage or in the case of severely impaired renal function, MAGNEVIST (gadopentetate dimeglumine) can be removed from the body by extracorporeal hemodialysis.

DOSAGE AND ADMINISTRATION
Special preparation of the patient for examination with MAGNEVIST (gadopentetate dimeglumine) is not required; however, precautionary measures should be taken with patients predisposed to seizure, e.g. close monitoring and availability of injectable anticonvulsants (see PRECAUTIONS). The usual safety rules for MRI (e.g. exclusion of ferromagnetic vascular clips) must be observed.
Young children, infants and neonates may require sedation prior to undergoing an MRI examination, in order to eliminate movement artifacts.
The following dosage guidelines apply to adults and children (including neonates and infants): MAGNEVIST has been shown to be effective in a wide range of field strengths (0.14 to 1.5 Tesla).

Important Note
The imaging procedure should be completed within one hour. Optimal contrast is generally observed in cranial investigations within 27 minutes following injection of MAGNEVIST and in spinal investigations during the early post administration phase (10 -30 minutes).
In neonates and infants, optimal CNS contrast has been observed to persist for several hours after MAGNEVIST administration.

Stability and Storage Recommendations
MAGNEVIST should be stored at 15-30ºC and protected from light.

Cardiovascular and Hemodynamic Effects
The cardiovascular and hemodynamic effects of gadopentetate dimeglumine were assessed in healthy anesthetized dogs following intravenous administration of 0.25 or 1.25 mmol/kg of body weight. A slight increase in peripheral resistance was noted at the lowdose level. Those dogs receiving 1.25 mmol/kg initially displayed reduced peripheral resistance, lower blood pressure and heart rate and an increase in the left ventricular enddiastolic pressure, stroke volume and cardiac output. Thereafter, the peripheral resistance increased and there was a significant increase in blood pressure which persisted at the same level for the remainder of the experiment.
The hemodynamic effects of gadopentetate dimeglumine were also assessed in dogs with acute ischemia-induced heart failure using doses of 0.25 mmol/kg and 0.75 mmol/kg intravenously. The 0.25 mmol/kg dose elicited a slight decrease in diastolic blood pressure and peripheral resistance and a slight increase in left ventricular dp/dt, cardiac output and stroke index. All parameters returned to the normal range five to ten minutes after administration. The 0.75 mmol/kg dose also elicited a similar transient response in hemodynamic parameters.

Renal Tolerance
The renal tolerance of gadopentetate dimeglumine was examined in rabbits following an intravenous dose of 2 mmol/kg. A slight effect on urinary protein excretion was seen in comparison to a sorbitol control solution; however gadopentetate dimeglumine exhibited better renal tolerance than other X-ray contrast agents. No effect was seen on serum creatinine or urea-nitrogen levels which served as indicators of renal function.
Furthermore, no histological effects could be detected in the kidneys after the one week observation period.

Physicochemical and Biochemical Properties
The pharmacological properties of gadopentetate dimeglumine were determined by a battery of in vitro and in vivo tests following intravenous administration in dogs, rabbits and baboons. Gadopentetate dimeglumine was shown to be highly hydrophilic and, consequently, had no protein binding ability and did not interfere with enzyme activity. In short, the compound was physiologically inert at concentrations anticipated for human use.

Effect on Coagulation
Gadopentetate dimeglumine was evaluated using thromboelastography and citrated dog blood for its in vitro effect on the coagulation process. Concentrations up to 29 mmol/L did not affect the coagulation process of citrated dog blood when compared with a control thromboelastogram obtained with normal saline.

Efficacy
The efficacy of gadopentetate dimeglumine was established in rats, rabbits and baboons following intravenous administration for diagnostic MRI. Intravenous doses of 0.01 -1.0 mmol/kg of body weight enhanced the contrast between healthy and pathological tissue (infarcts, tumors and inflammations). Since gadopentetate dimeglumine was excreted in the urine, it also enhanced renal contrast in the rat at doses as low as 0.01 mmol/kg of body weight.

Pharmacokinetics
Gadopentetate dimeglumine was administered orally and/or intravenously in the rat (males, pregnant females or lactating females), rabbit (pregnant females), dog (females) and baboon (males) to investigate absorption, distribution, metabolism and excretion.
After oral administration, radiolabelled gadopentetate dimeglumine was not absorbed or very poorly absorbed from the gastrointestinal tract of rats and dogs and was excreted almost completely in the faeces (ca. 100% in the rat and 94% in the dog).
After intravenous injection, the compound was excreted primarily in the urine (90% in the rat and >96% in the dog). In renally-impaired rats, biliary excretion of radiolabelled gadopentetate accounted for 2% of the dose in four hours when both kidneys were occluded.
Intravenous doses of gadopentetate dimeglumine did not result in any significant accumulation in tissues studied in the rat, rabbit, dog or baboon. However, in rats with total renal impairment, 3.5% of the radiolabelled gadopentetate dimeglumine dose was secreted into the stomach and bowel four hours after intravenous administration. These results suggest that this compound can be secreted into the gastrointestinal tract, particularly when severe renal impairment exists.
Following single intravenous administrations of radiolabelled gadopentetate dimeglumine (0.5 mmol/kg) to pregnant rabbits, peak concentrations of radiolabelled gadolinium in the fetuses appeared after 30 minutes. In the dam plasma, liver, heart and uterus concentrations remained stable after 15 and 30 minutes. Fetal tissue concentrations were ca. 4% after 15 minutes and 8% after 30 minutes of that in the dams' plasma (corresponding to 0.11% and 0.26% of the total dose, respectively). By 120 minutes, fetal concentrations decreased to 1/4 of peak value. The fetal elimination half-life was 30-50 minutes, similar to that of maternal plasma and tissue.
Following intravenous administrations of radiolabellled gadopentetate dimeglumine to pregnant rats, the compound was shown to be rapidly distributed, did not pass the bloodbrain or placental barriers and cleared within 24-hours post-administration.
In lactating rats that were given intravenous administrations of the radiolabelled gadopentetate dimeglumine less than 0.2% of the administered dose was transferred to the offspring via the maternal milk.

Clinical Laboratory Evaluations
Clinical laboratory evaluations revealed elevations in serum iron and, in some cases, serum bilirubin levels, which were considered to be definitely drug-related. In about 15% of female and 30% of male patients, increases in serum iron levels above baseline were noted. The increases appeared within 2 to 4 hours post-injection and declined within 24 hours post-injection. By 48 hours post-injection the levels had returned to baseline.
Hemoglobin, hematocrit, red blood cell count and liver function enzymes were unaffected.
This effect is considered to be due to a slight degree of hemolysis, probably extravascular and too small to result in a change in hemoglobin, hematocrit, or red blood cell count.
Although MAGNEVIST is not a risk for patients with normal hematological status, it is possible that those patients with hematolytic anemia may be at an increased risk, since gadopentetate dimeglumine appears to exert an effect on red blood cell morphology.
About 8% of the patients who show a rise in serum iron levels also show a rise in serum bilirubin levels, apparently because these patients are somewhat less efficient in conjugating bilirubin resulting from hemolysis.

Clinical Studies in Adults with Cranial and Spinal Lesions
The efficacy of MAGNEVIST as an MRI contrast enhancement agent in the diagnosis and evaluation of brain lesions and lesions of the spine and associated tissues was

Clinical Studies in Children with Cranial and Spinal Lesions
The efficacy of MAGNEVIST was demonstrated in two pivotal clinical studies, involving 142 children with a preliminary diagnosis of CNS abnormality, based upon diagnostic methods other than MRI. Their ages ranged from newborn to 18 years. MRI was performed on all patients before and after the administration of 0.2 mL/kg (0.1 mmol/kg) MAGNEVIST.
Some patients were given an additional 0.1 mmol/kg dose within 30 minutes of the first dose, if this was necessary to make a diagnosis.
Contrast evaluations: after MAGNEVIST injection the contrast-to-noise ratio of the magnetic resonance images increased notably, with a further increase in those patients receiving a second MAGNEVIST injection. The signal intensity ratio of lesion to normal tissue was significantly increased for head and spinal T1 scans after MAGNEVIST injection.
Investigator ratings of lesion contrast compared to normal tissue, and of lesion demarcation compared to surrounding tissue, improved after MAGNEVIST injection. Most ratings progressed from "none" or "poor" to "excellent". In the blinded reader evaluation, post-MAGNEVIST contrast scores were higher than pre-MAGNEVIST scores in 36 of 66 (55%) patients (p<0.001).

Acute Toxicity
Acute intravenous studies have been carried out with gadopentetate dimeglumine in mice, rats and dogs. Acute oral toxicity studies have been carried out in mice and rats.

Mutagenicity Studies
Gadopentetate dimeglumine was evaluated for its mutagenic potential in vitro using both bacterial assays (S. typhimurium, E. coli) and mammalian tests (HGPRT test in V 79 cells, UDS test in hepatocytes, cellular transformation assay in C3H 10T1/2 cells); in vivo, the product was assessed using two different systems, namely the micronucleus test and dominant lethal assay.
There was no indication that gadopentetate dimeglumine possesses any mutagenic potential in vitro or in vivo.

Rosenbaum pocket vision screener
The Rosenbaum pocket vision screener is a hand-held eye chart to determine whether a patient's visual acuity is adequat to perform tests in the MACFIMS. Small print characters presented during the testing are similar to the characters presented at the 20/50-70 threshold when the Rosenbaum card is positioned 14 inches from the corrected eye. Instruction: Card is held in good light 14 inches from the corrected eye. Record vision for both eyes with glasses or contact lenses (should the patient use such devices).
Patient shall read the first line (i.e. 9, 5), then the second line and so forth.
Say: "Please, read aloud the first line!" "Please, read aloud the second line!" ..... and so forth Please, look at the score-column called "distance equivalent". Write down the score-number shown in that line which the patient is not able to read (e.g. "20/30"). If the patient is able to read even the last line, score him "20/20". If the patient is unable to read symbols at 20/70, do not administer SDMT, D-KEFS, and WTAR.

Wechsler Test of Adult Reading Ability (WTAR)
The WTAR is applied to investigate the pre-morbid cognitive ability and as such serves the purpuse to evaluate potentially confounding factors during the neuropsychological testing.
Instructions for WTAR: Begin administration of the WTAR by saying: I will show you some words that I will ask you to pronounce Place the WTAR word card (cf. below) in front of the examinee. As you point to the card, say: Beginning with the first word on the list, pronounce each word aloud. Start with this word (point to Item 1), and go down this column, one right after the other, without skipping any. When you finish this column, go to the next column (point to the second column). Pronounce each word even if you are unsure. Do you understand?
If the examinee does not understand the instructions, you may repeat the instructions, paraphrasing if necessary.
When you are sure that the examinee understands the task, say,

Ready? Begin.
Recording and Scoring: Acceptable pronunciations, including alternate pronunciations, for the WTAR words are provided on the record form and pronunciations tape. The examinee is required to give only one pronunciation of a word. Award one point for each correct response and 0 points for each incorrect response. Sum the points to obtain the WTAR raw score. The maximum score is 50. Before proceeding, make sure that the examinee understands the task. Then read aloud the target words of List A at an even pace at a rate slightly longer than one second per word. The entire list should take a total of 18 to 20 seconds to read.
After reading the last word on the list, say: Go ahead.
Write the examinee's responses, including repetitions and intrusions, verbatim in the order in which they are recalled, in the column labeled 'TRIAL 1' on the record form.
Approximately 15 seconds after the examinee appears to have given his or her last response on a trial, or when the examinee indicates that he or she cannot remember any more words, provide a single prompt, such as:

Anything else?
Mark 'Q' on the next blank line in the response column to indicate when the prompt was given. Record any responses reported by the examinee after the prompt.

TRIAL 2 -Say:
I'm going to read the same list again. Like before, tell me as many of the words as you can, iln any order. Be sure to also say words from the list that you told me the first time.
Again, read the words of List A aloud at an even pace at a rate slightly longer than one second per word. The entire list should take a total of 18 to 20 seconds to read. Record the examinee's responses in the column labeled TRIAL 2 on the record form. Follow the same procedures for recording and prompting that were used for TRIAL 1.
For TRIALS 3 and 4, say: I'm going to read the same list again. Like before, tell me as many of the words as you can, in any order, including words from the list you've said before.
Follow the same procedures for reading the List A words, recording responses, and prompting as were used for the previous trials. Record the examinee's responses in the columns labeled TRIAL 3 and TRIAL 4 on the Record Form. Allow subject to work for 90 seconds. The test boxes of List A are shown below:

Overview
The EDSS assessment is based on the standardized neurological examination according to Kurtzke's functional systems and the standard measure of neurological status in MS (Kurtzke 1983). The neurological examination covers the following functional systems: Each functional system is represented by a number of items; for each item, the level of impairment will be scored. In addition, for each functional system (except ambulation), the Kurtzke Functional System Score ranging from grade 0 (normal) to grade 5 or grade 6 will be recorded.
Integrating the assessments of all functional systems, the EDSS score will be determined, ranging from 0.0 (normal) to 10.0 (dead). severe Sustained nystagmus in primary position or coarse persistent nystagmus in any direction interfering with visual acuity, complete internuclear ophthalmoplegia with sustained nystagmus of abducting eye, oscillopsia

Limb strength
The weakest muscle in each group defines the score for that group. Each movement should be tested, but only pathological findings should be noted using the BMRC grades. Use of functional tests like jumping with one foot, walking on toes or heels are recommended in order to assess grades 3-5 BMRC.

Completing the record form
Record any circumstances that you believe may have affected the patient's performance. These are factors that may have affected the trial but were not severe enough to necessitate repetition of the trial: -The patient had a cold or reports not feeling well.
-The patient tripped but did not fall.
If a situation arises that necessitates the repetition of a trial, indicate the reason a trial had to be repeated on the Record Form. Examples of reasons to repeat a trial include, but are not limited to, the following: -The patient fell during the walk.
-Examiner forgot to start or stop stopwatch.
-Examiner forgot to reset stopwatch in between trials.
-The patient stopped to talk to someone while walking, or another person/thing somehow interfered with walk.
Record only the times for the two successfully completed trials of the timed 25-foot walk. If the patient could not complete one or both of the trials of the timed 25-foot walk, record this in the appropriate section of the Record Form. For example, if the patient's disease has progressed and/or physical limitations prohibit him or her from completing the trial, you should indicate "Unable to complete trial due to physical limitations", and record any specifics that you can observe (i.e., patient in a wheelchair now and unable to walk, etc.). If the patient did not complete a trial for any other reason, specify this as well (e.g., patient fell and was too fatigued to complete another trial; patient refused to complete trial).

Q. Does it matter what kind of shoes the patient wears?
A. As long as the style of the shoe is consistent for each patient from visit to visit, it does not matter what kind of shoes are worn. Encourage the patient to wear comfortable shoes and discourage patients from wearing, for example, high-heeled shoes one visit and running shoes the next.
Q. Is the patient allowed to pause while walking the 25-foot distance?
A. The patient should be encouraged to walk at a steady pace, one that he or she can sustain for 25 feet (7.62 m). However, pauses are allowed as long as the patient can complete the walk within the 3-minute time limit.
A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 20 August 2004

Completing the record form
Record any circumstances that you believe may have affected the patient's performance. These are factors that may have affected the trial, but were not severe enough to necessitate repetition of the trial. Examples include (but are not limited to) the following: -The patient dropped a peg.
-The patient has a cold.
-The patient forgot eyeglasses and had difficulty seeing pegs.
-The patient talked during the task.
If a trial is repeated, indicate this and specify the reason it had to be repeated. Examples of reasons to repeat a trial include the following: -The patient knocked entire apparatus on the floor.
-The examiner forgot to start or stop stopwatch.
-The examiner forgot to reset the stopwatch in between trials.
Record only the times for the two successfully completed trials for each hand on the 9-HPT. If the patient could not complete one or both of the trials for either hand of the 9-HPT, record this in the appropriate section of the Record Form.
If the patient's disease has progressed and/or physical limitations prohibit him or her from completing the trial, the examiner should mark "Unable to complete trial due to physical limitations" and then record any specifics that can be observed (e.g. "patient unable to use right hand, patient could not complete within time limit" etc.). If the patient did not complete a trial for any other reason, describe the specific circumstances (e.g. "patient refused").

Questions and answers
Q. Is the patient allowed to take a break between the Timed Walk and the 9-HPT?
A. Yes, but the patient is only allowed to rest a maximum of 5 minutes after the Timed Walk before starting the 9-HPT.

Q. How should I determine the dominant hand if the patient indicates that he or she uses both hands?
A. The dominant hand is the hand with which the patient writes (or did write) the majority of the time.
A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 20 August 2004 Administer the practice sequence a maximum of three times. Record answers in the space provided on the back of the PASAT Record Form. Between the initial training session and the first actual administration of the test, the patients should be allowed a break of approximately ½ hour.

PASAT
Once it is clear that the patient possesses sufficient understanding of the task, begin the actual test. Before starting the test, remind him/her: "Remember, if you get lost, just jump back in because I can't stop the test once it has begun." Discourage talking and oral calculations during the test; only the patient's answers should be spoken out loud. The patient may need prompting to continue the test if she/he gets lost. After five consecutive 'no responses', redirect the patient quickly by saying, "Jump back in", but do not stop the CD.

Completing the record form
Circle all correct answers. Write in any incorrect responses in the space provided. Write "NR" (for "no response") when no response was given. If the patient corrects him/herself after giving a response, count the amended answer as the response. The amended response is the one that will be used in determining total correct, regardless of whether it was the correct or incorrect response. Slash through the old response and write in 'SC' with a circle around it to indicate that the patient self-corrected.
Each section of the PASAT has a maximum of 60 correct answers (i.e. 61 digits are presented for each part). Count the total number correct (number of circled answers) for the PASAT and record on both the PASAT Record Form and the Summary Score Sheet.
Finally, record any circumstances that you believe may have affected the patient's performance. These are factors that may have affected the trial, but were not severe enough to necessitate repetition of the trial. Examples include, but are not limited to, the following: -Subtle noises outside of the testing room.
-Patient reports frustration or mild distress.
-Patient talked during test (other than to give answers).
If a trial must be repeated, indicate this and specify the reason why it had to be repeated. Examples of reasons to repeat a trial include, but are not limited to the following: -Test interrupted (e.g. someone walked into the room or other major disturbance).
-Examiner error, such as starting the wrong CD track or using the wrong form.

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A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 20 August 2004 The following group of genes are of interest with regard to the mechanism of action and, potentially, the efficacy of Betaseron ® : -Major components of the signaling pathways of the interferon beta type I receptor, e.g. the JAK family of tyrosine kinases and the STAT family of transcription factors.
-Further downstream, via the activation of this signaling pathway, a large number of genes is either induced or their expression down-regulated. All these genes are also of interest as their gene expression changes might be contribute to the effects of Betaseron ® .
Furthermore, Professor Ebers' laboratory in Oxford has recently identified a genetic marker which appears to differentiate between patients having a malignant compared to a benign course. Further details would be available at request. These findings derived as they are from the Natural History database and other patients from London (Ontario) have not been applied yet to patients in a clinical trial. The collection of long-term outcome information on this original cohort should allow for evaluation of trial-related outcome in the context of variable compliance with a continuation of therapy in an exploratory fashion. It is planned to use 4 mL of EDTA blood for this purpose.
The following institutions will be involved:

Ethical and data privacy considerations
Pharmacogenetic analyses will focus on and be restricted to MS-related and/or MS-treatment-related genes of interest. Since both, the disease and the treatment response (efficacy and safety/tolerability) of Betaseron ® are far from being fully understood there may be a high number of potential genes of interest.
For all pharmacogenetic activities and evaluations, a separate patient's informed consent must be obtained (cf. Appendix 2 to this protocol). The patient may decide to participate in pharmacogenetic evaluations independent of her/his decision to participate in the clinical study. The patient can withdraw her/his DNA sample at any time independent of his/her participation in the clinical study. The signed informed consent forms are stored separately from other study-related documentation, A long-term follow-up of patients enrolled in the pivotal study of Betaseron ® (interferon beta 1b) in relapsing-remitting multiple sclerosis 20 August 2004

The Pharmacogenetic Advisory Board and other bodies involved
For further review and advice a Pharmacogenetic Advisory Board (PGAB) is established with external experts in pharmacogenetics, biomedical sciences, ethics and law and representatives from Corporate Pharmacogenomics. The external experts form the majority. The PGAB approves the general procedures as they are laid down in this SOP and other relevant documents. It is informed and asked for advice by CPG on all study protocols involving PGt sampling or analyses, and whenever non-prespecified PGt analyses are to be performed. In this review process it has a veto right which can only be overruled by a decision of the member responsible for research and development in the Board of Executive Directors, SAG. The review of the study protocol can take place in parallel to seeking approval by the local ethics committees and local authorities where appropriate.
In case of non-prespecified PGt analyses, the supplemental study protocol describing the specified analyses to be done is given to the PGAB for review via CPG.
The PGAB also has to be involved in the decision making on the potential relevance of results of PGt analyses and on the need to inform the investigators with regard to counseling of patients.
Where applicable, the PGAB has to consult with any body involved in safeguarding a study (e.g. the Steering Committee and the Advisory Board of the study).

Responsibilities regarding initiation of pharmacogenetic sampling
The study manager (SAG function in studies sponsored by SAG Group companies) has the following responsibilities with regard to initiating PGt sampling: -The study manager informs the CSR and the CPG function about the logistics used in the trial that is planned to include PGt analyses.
-She/he has to inform the relevant CCO-SI function in a timely manner about the planned sampling and about the CSR contact person(s) to which the key code list for the DNA sample ID has to be communicated.
-She/he is responsible for the actual set up of the sampling in the centers, the logistics up to the arrival at the CSR (where CPG takes custody) and the operational aspects of organizing the PGt testing and analyses in a particular study. CPG will provide support where needed.
-She/he is responsible for obtaining approval from the relevant local ethics committee(s) and local authorities where applicable for sampling for PGt analyses in a given clinical study.
-She/he is responsible for updating and archiving the table shown in appendix A.
The investigator has the following responsibilities with regard to initiating PGt sampling: -The investigator must obtain informed consent of the patients for participation in the PGt part of the study after approval of the pharmacogenetic testing and analyses by the relevant local ethics committee(s) and (where applicable) local authorities. She/he is responsible for archiving the informed consent form separately from the patient file.